Inpatient Opioid Consumption Variability following Total Knee Arthroplasty: Analysis of 4,038 Procedures

Abstract

This study examined an early iteration of an inpatient opioid administration-reporting tool, which standardized patient opioid consumption as an average daily morphine milligram equivalence per surgical encounter (MME/day/encounter) among total knee arthroplasty (TKA) recipients. The objective was to assess the variability of inpatient opioid administration rates among surgeons after implementation of a multimodal opioid sparing pain protocol. We queried the electronic medical record at our institution for patients undergoing elective primary TKA between January 1, 2016 and June 30, 2018. Patient demographics, inpatient and surgical factors, and inpatient opioid administration were retrieved. Opioid consumption was converted into average MME for each postoperative day. These MME/day/encounter values were used to determine mean and variance of opioids prescribed by individual surgeons. A secondary analysis of regional inpatient opioid consumption was determined by patient zip codes. In total, 23 surgeons performed 4,038 primary TKA. The institutional average opioid dose was 46.24 ± 0.75 MME/day/encounter. Average intersurgeon (IS) opioid prescribing ranged from 17.67 to 59.15 MME/day/encounter. Intrasurgeon variability ranged between ± 1.01 and ± 7.51 MME/day/encounter. After adjusting for patient factors, the average institutional MME/day/encounter was 38.43 ± 0.42, with average IS variability ranging from 18.29 to 42.84 MME/day/encounter, and intrasurgeon variability ranging between ± 1.05 and ± 2.82 MME/day/encounter. Our results suggest that there is intrainstitutional variability in opioid administration following primary TKA even after controlling for potential patient risk factors. TKA candidates may benefit from the implementation of a more rigid standardization of multimodal pain management protocols that can control pain while minimizing the opioid burden. This is a level of evidence III, retrospective observational analysis.

Adductor canal catheter block after total knee arthroplasty in patients with severe osteoarthritis and limited mobility. A single center study in Riyadh, Saudi Arabia

“…They reported an average of 46.24 ±0.75 MME/day/patient encounter and a lack of consistency between institutions. [ 14 ] Roof et al . 's study highlights the necessity of continued innovation to reach a standardized pain control regimen.…”

Predictive Factors for Postoperative Opioid Use in Elective Skull Base Craniotomies

“…In an attempt to compare skull base craniotomies to other surgical procedures, we identified studies in the literature that report MME over 24 to 72 hours postoperatively for other surgical procedures ( Table 6 ). 10 11 12 13 14 15 In comparison, patients undergoing head and neck procedures require significantly fewer opioids than skull base craniotomies. Published benchmarks include endoscopic sinus surgery (23.1 mean MME at 24 hours postoperatively), 10 orthognathic surgery (48.0 mean MME at 24 hours postoperatively), 11 and nonaerodigestive head and neck surgery (40.5 ± 30.6 MME within the 24-hour postoperative period).…”

“…13 Bernstein et al 14 identified that patients who underwent primary total hip arthroplasty required 44.03 mean MME, significantly less compared with patients who underwent revision total hip arthroplasty, who required 135.5 mean MME at 24 hours after surgery. Total knee arthroplasty was found to require an average of 38.43 ± 0.42 MME per day when adjusting for patient factors such as body mass index, smoking status, insurance, and race according to Roof et al 15…”

“…In an attempt to compare skull base craniotomies to other surgical procedures, we identified studies in the literature that report MME over 24 to 72 hours postoperatively for other surgical procedures (►Table 6). [10][11][12][13][14][15] In comparison, patients undergoing head and neck procedures require significantly fewer opioids Skull base craniotomy fell within the range seen in other spine and joint procedures. Patients who underwent lumbar decompression, lumbar decompression with fusion, or cervical decompression with fusion consumed 19.7 AE 0.9, 105.3 AE 4.1, and 65.0 AE 2.0 MME postoperatively daily, respectively.…”

Dramatic Reduction in Opioid Prescribing for Common Outpatient Orthopaedic Lower Extremity Surgical Procedures at a Louisiana University-Based Safety-Net Hospital After Enactment of Opioid-Limiting State Legislation

“…11 In addition, there is considerable variability among surgeons, institutions, and states in opioid prescribing for the same orthopaedic procedure. 8,[12][13][14][15] To reduce and standardize opioid prescribing in general and after orthopaedic surgery specifically, initiatives have been launched by various stakeholders, including professional organizations, 16 and state 17 and federal 18 government agencies and bodies. The recently published guidelines developed by the Orthopaedic Trauma Association (OTA) Musculoskeletal Pain Task Force recommend the use of multimodal analgesia and prescribing the lowest effective immediate-release opioid for the shortest period possible for patients with acute musculoskeletal injuries.…”