Use of tranexamic acid does not influence perioperative outcomes in ambulatory foot and ankle surgery-a prospective triple blinded randomized controlled trial
STUDY OBJECTIVE/OBJECTIVE:TXA is an antifibrinolytic medication widely used to reduce perioperative blood loss, but it has been seldom used during foot and ankle surgery. Our study evaluates the impact of TXA use on blood loss, post-operative pain, peri-operative opioid consumption, and wound healing in ambulatory outpatient foot and ankle procedures. DESIGN/METHODS:Prospective, triple-blinded, randomized controlled trial. SETTING/METHODS:Peri-operative environment of a major academic health centre in New York City. PATIENTS/METHODS:A total of 100 participants who were scheduled for ambulatory foot and ankle surgery with a single surgeon. INTERVENTIONS/METHODS:Patients receive either 10Â mg/kg TXA (TXA group) or 10Â ml/kg of normal saline (placebo group) intravenously prior to skin incision. MEASUREMENTS/METHODS:Primary outcome was intra-operative blood loss. Secondary outcomes were peri-operative opioid consumption and wound complications between post-operative days 14 and 21. MAIN RESULTS/RESULTS:We found no difference between TXA and placebo groups in terms of intra-operative blood loss, p value 0.71, 95% CI (63.13-19.80). There was no difference between the two groups in terms of post-operative morphine milliequivalents (MME). The incidence of wound complications was 16.3% in the TXA group compared to 15.7% in the placebo group with OR 1.04, p value 0.93, 95% CI (0.32-2.77). No adverse events associated with TXA were reported. CONCLUSIONS:The use of TXA during foot and ankle surgery was not associated with any benefits in perioperative outcomes in our outpatient ambulatory surgical population. Considering potential risks, we do not support the routine use of TXA in this surgical model.
Peroneal nerve palsy following shoulder surgery [Letter]
Comparison of clinical outcomes of acetaminophen IV vs PO in the peri-operative setting for laparoscopic inguinal hernia repair surgeries: A triple-blinded, randomized controlled trial
BACKGROUND:Acetaminophen is available in a variety of modalities but there is conflicting evidence as to whether intravenous provides superior analgesia than oral formulations METHODS: A prospective, randomized, triple-blinded clinical trial was conducted in which 100 participants, scheduled for any laparoscopic unilateral hernia repair surgery in the ambulatory setting, were computer randomized to receive either 975â€¯mg oral acetaminophen or 1000â€¯mg of intravenous acetaminophen. The primary outcomes evaluated were post-anesthesia care unit (PACU) pain scores at arrival, 1â€¯hour discharge, 6â€¯hour post-op as well as total opioid use intraoperatively and in PACU. Secondary outcomes were PACU length of stay, patient reported total opioid use in the first 24â€¯h, pain scores 24â€¯hour post-op and patient satisfaction. RESULTS:We found that no significant difference was appreciated between the oral and intravenous acetaminophen groups in any of the primary or secondary outcomes with the p-value of the pain score on arrival of 0.173, pain score at 1â€¯h 0.544, pain score on discharge from PACU 0.586, pain score at 6â€¯h 0.234, pain score at 24â€¯h 0.133, total morphine milligram equivalents (MME) intraoperatively 0.096, total MME in PACU 0.960, time in PACU 0.15, home opioid MME 0.336, and overall patient satisfaction 0.067. CONCLUSIONS:We concluded that in the ambulatory surgery population the efficacy of oral and intravenous acetaminophen is equivalent.
Usefulness of the opioid risk tool to predict aberrant drug-related behavior in patients receiving opioids for the treatment of chronic pain
OBJECTIVE:The purpose of this study was to determine if the opioid risk tool (ORT) was clinically useful in guiding physician decision making during chronic opioid therapy and to determine whether there were differences between the patient-completed and physician-completed ORT. DESIGN/METHODS:Retrospective review of prospectively collected data. SETTING/METHODS:A single-center tertiary care outpatient pain management center. PATIENTS, PARTICIPANTS/METHODS:One-hundred twenty-five patients who received chronic opioids as part of their pain therapy. INTERVENTIONS/METHODS:Patients receiving care were asked to complete the ORT as part of their initial evaluation. In addition, as part of this study, a pain physician reviewed the information available at the time of the initial evaluation and completed the ORT. Medical records were reviewed for evidence of moderate-to-severe aberrant drug-related behavior (ADRB), according to specified criteria. MAIN OUTCOME MEASURES/METHODS:Patient-completed and physician-completed ORT and presence or absence of moderate to severe ADRB. RESULTS:Of the 125 patients included in this study, physician-completed ORT was available for 125 patients, and a patient-completed ORT was available on 87 of these patients. There was good correlation between the patient-completed and physician-completed ORT (correlation coefficient = 0.61). There were 112 observations of ADRB in 53 of 125 patients (42.4 percent) during the observation period of an average of 7.8 months (range 2-17 months). Of these 53 patients, 32 (60.4 percent) were identified by urine drug screen (UDS) alone, 7 (13.2 percent) were identified by physician observation alone, and 14 (26.4 percent) were identified by both UDS and physician observation. Based on the physician-completed ORT, 41 of 106 (38.7 percent) low risk patients had ADRB, compared to 8 of 14 (57.1 percent) moderate risk, and 4 of 5 (80 percent) high risk patients. CONCLUSIONS:Neither the patient-completed nor the physician-completed ORT was strongly predictive of moderate-to-severe ADRB in patients receiving chronic opioid therapy for the treatment of noncancer pain in our pain center.
Retrospective review of physician opioid prescribing practices in patients with aberrant behaviors
In the past few decades, opioid use for the treatment of chronic noncancer pain has slowly gained acceptance. With this increase in prescription opioid use, there has also been an increase in prescription opioid abuse. To help detect aberrant drug related behaviors, clinicians have utilized urine drug screens to determine patient noncompliance in outpatient pain clinics. The primary objective is to determine how the use of urine drug testing (UDT) affects health care outcomes. The secondary outcome is to evaluate these findings as it relates to pharmacoeconomics and aberrant behaviors in an outpatient clinical setting. In this study we will determine if UDT influences prescribing practices among physicians. Patients at an academic center's chronic pain outpatient clinic were categorized as having urine screens that were "normal" (expected findings based on their prescribed drugs) or abnormal. Abnormal findings were those with either 1) the absence of a prescribed opioid, 2) the presence of an additional nonprescribed controlled substance, 3) detection of an illicit substance, or 4) an adulterated urine sample. We examined the incidence of such aberrant behaviors as well as concomitant pain diagnoses, psychiatric comorbidities, and the ultimate effect upon the prescribing patterns of the physicians in this clinic. Results of the study showed that the patients exhibiting aberrant drug behaviors have similar pain and psychiatric diagnoses as other chronic pain patients. The most common aberrancy detected was an abnormal urine drug screen, often with the presence of illegal substances. However, in the great majority of aberrancies detected, providers chose to continue prescribing opioids. We speculate on the reasons for this, and discuss the role of the urine drug screen in influencing prescriber behaviors.