Association of Multimodal Pain Management Strategies with Perioperative Outcomes and Resource Utilization

Abstract

Background Multimodal analgesia is increasingly considered routine practice in joint arthroplasties, but supportive large-scale data are scarce. The authors aimed to determine how the number and type of analgesic modes is associated with reduced opioid prescription, complications, and resource utilization. Methods Total hip/knee arthroplasties (N = 512,393 and N = 1,028,069, respectively) from the Premier Perspective database (2006 to 2016) were included. Analgesic modes considered were opioids, peripheral nerve blocks, acetaminophen, steroids, gabapentin/pregabalin, nonsteroidal antiinflammatory drugs, cyclooxygenase-2 inhibitors, or ketamine. Groups were categorized into “opioids only” and 1, 2, or more than 2 additional modes. Multilevel models measured associations between multimodal analgesia and opioid prescription, cost/length of hospitalization, and opioid-related adverse effects. Odds ratios or percent change and 95% CIs are reported. Results Overall, 85.6% (N = 1,318,165) of patients received multimodal analgesia. In multivariable models, additions of analgesic modes were associated with stepwise positive effects: total hip arthroplasty patients receiving more than 2 modes (compared to “opioids only”) experienced 19% fewer respiratory (odds ratio, 0.81; 95% CI, 0.70 to 0.94; unadjusted 1.0% [N = 1,513] vs. 2.0% [N = 1,546]), 26% fewer gastrointestinal (odds ratio, 0.74; 95% CI, 0.65 to 0.84; unadjusted 1.5% [N = 2,234] vs. 2.5% [N = 1,984]) complications, up to a –18.5% decrease in opioid prescription (95% CI, –19.7% to –17.2%; 205 vs. 300 overall median oral morphine equivalents), and a –12.1% decrease (95% CI, –12.8% to –11.5%; 2 vs. 3 median days) in length of stay (all P < 0.05). Total knee arthroplasty analyses showed similar patterns. Nonsteroidal antiinflammatory drugs and cyclooxygenase-2 inhibitors seemed to be the most effective modalities used. Conclusions While the optimal multimodal regimen is still not known, the authors’ findings encourage the combined use of multiple modalities in perioperative analgesic protocols.

Effectiveness of intravenous acetaminophen for postoperative pain management in hip and knee arthroplasties: a population-based study

“…Moreover, the incidence of immediate postoperative adverse events can readily be reduced by the use of multiple analgesic modalities. In patients undergoing TJA, Memtsoudis et al 26 found a stepwise beneficial effect for each non-opioid analgesic modality that is added to the strategy, including regional anesthesia, APAP, steroids, gabapentinoids, NSAIDs, COX-2 inhibitors, or ketamine. Patients who received more than two additional modalities (as compared with ‘opioids only’) were found to have significantly lower risk for respiratory (−19%) and gastrointestinal (−26%) complications, lower opioid utilization (−18.5% OME), and shorter length of stay (−12.5% days).…”

Perioperative opioid analgesia—when is enough too much? A review of opioid-induced tolerance and hyperalgesia

“…Use of more than one type of non-opioid analgesic may have most impact on opioid consumption, although there are a limited number of studies assessing combination analgesia. Use of at least two non-opioid approaches may reduce adverse effects, such as respiratory depression, gastrointestinal dysfunction, as well as reducing opioid requirements (80,81).…”

The Hemodynamic Effect of Epinephrine-Containing Local Infiltration Analgesia After Tourniquet Deflation During Total Knee Arthroplasty: A Retrospective Observational Study

“…In addition, there might be an additive analgesic effect even when LIA was added to a standardized multimodal regimen including adductor canal block [19]. Given that multimodal analgesia has become the standard of care for patients undergoing joint arthroplasty [20], use of LIA is expected to increase in these patients. Furthermore, LIA appears to be preferred because it is an analgesic modality that can be administered by the surgeon intraoperatively.…”