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Patient-controlled epidural analgesia or multimodal pain regimen with periarticular injection after total hip arthroplasty: a randomized, double-blind, placebo-controlled study.
J Bone Joint Surg Am. 2015 May 20; 97(10):789-98.JB

Abstract

BACKGROUND

The optimal postoperative analgesia after primary total hip arthroplasty remains in question. This randomized, double-blind, placebo-controlled study compared the use of patient-controlled epidural analgesia (PCEA) with use of a multimodal pain regimen including periarticular injection (PAI). We hypothesized that PAI would lead to earlier readiness for discharge, decreased opioid consumption, and lower pain scores.

METHODS

Forty-one patients received PAI, and forty-three patients received PCEA. Preoperatively, both groups were administered dexamethasone (6 mg, orally). The PAI group received a clonidine patch and sustained-release oxycodone (10 mg), while the PCEA group had placebo. Both groups received combined spinal-epidural anesthesia and used an epidural pain pump postoperatively; the PAI group had normal saline solution, while the PCEA group had bupivacaine and hydromorphone. The primary outcome, readiness for discharge, required the discontinuation of the epidural, a pain score of <4 (numeric rating scale) without parenteral narcotics, normal eating, minimal nausea, urination without a catheter, a dry surgical wound, no acute medical problems, and the ability to independently transfer and walk 12.2 m (40 ft).

RESULTS

The mean time to readiness for discharge (and standard deviation) was 2.4 ± 0.7 days (PAI) compared with 2.3 ± 0.8 days (PCEA) (p = 0.86). The mean length of stay was 3.0 ± 0.8 days (PAI) compared with 3.1 ± 0.7 days (PCEA) (p = 0.46). A significant mean difference in pain score of 0.74 with ambulation (p = 0.01; 95% confidence interval [CI], 0.18 to 1.31) and 0.80 during physical therapy (p = 0.03; 95% CI, 0.09 to 1.51) favored the PCEA group. The mean opioid consumption (oral morphine equivalents in milligrams) was significantly higher in the PAI group on postoperative day 0 (43 ± 21 compared with 28 ± 23; p = 0.002) and postoperative days 0 through 2 (136 ± 59 compared with 90 ± 79; p = 0.004). Opioid-Related Symptom Distress Scale (ORSDS) composite scores for severity and bothersomeness as well as scores for nausea, vomiting, and itchiness were significantly higher in the PCEA group (p < 0.05). Quality of Recovery-40 scores and patient satisfaction were similar.

CONCLUSIONS

PAI did not decrease the time to discharge and was associated with higher pain scores and greater opioid consumption but lower ORSDS scores compared with PCEA. The choice for analgesic regimen may depend on a particular patient's threshold for pain and the potential side effects.

Authors+Show Affiliations

Departments of Anesthesiology (K.M.J.-E., A.K.G., Y.L., R.L.K., D.D.B., E.A.G., S.C.R., J.C., J.T.Y.) and Orthopedic Surgery (G.H.W., D.E.P., D.J.M., A.S.R., C.S.R.), Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for K.M. Jules-Elysee: juleselyseek@hss.edu.Departments of Anesthesiology (K.M.J.-E., A.K.G., Y.L., R.L.K., D.D.B., E.A.G., S.C.R., J.C., J.T.Y.) and Orthopedic Surgery (G.H.W., D.E.P., D.J.M., A.S.R., C.S.R.), Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for K.M. Jules-Elysee: juleselyseek@hss.edu.Departments of Anesthesiology (K.M.J.-E., A.K.G., Y.L., R.L.K., D.D.B., E.A.G., S.C.R., J.C., J.T.Y.) and Orthopedic Surgery (G.H.W., D.E.P., D.J.M., A.S.R., C.S.R.), Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for K.M. Jules-Elysee: juleselyseek@hss.edu.Departments of Anesthesiology (K.M.J.-E., A.K.G., Y.L., R.L.K., D.D.B., E.A.G., S.C.R., J.C., J.T.Y.) and Orthopedic Surgery (G.H.W., D.E.P., D.J.M., A.S.R., C.S.R.), Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for K.M. Jules-Elysee: juleselyseek@hss.edu.Departments of Anesthesiology (K.M.J.-E., A.K.G., Y.L., R.L.K., D.D.B., E.A.G., S.C.R., J.C., J.T.Y.) and Orthopedic Surgery (G.H.W., D.E.P., D.J.M., A.S.R., C.S.R.), Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for K.M. Jules-Elysee: juleselyseek@hss.edu.Departments of Anesthesiology (K.M.J.-E., A.K.G., Y.L., R.L.K., D.D.B., E.A.G., S.C.R., J.C., J.T.Y.) and Orthopedic Surgery (G.H.W., D.E.P., D.J.M., A.S.R., C.S.R.), Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for K.M. Jules-Elysee: juleselyseek@hss.edu.Departments of Anesthesiology (K.M.J.-E., A.K.G., Y.L., R.L.K., D.D.B., E.A.G., S.C.R., J.C., J.T.Y.) and Orthopedic Surgery (G.H.W., D.E.P., D.J.M., A.S.R., C.S.R.), Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for K.M. Jules-Elysee: juleselyseek@hss.edu.Departments of Anesthesiology (K.M.J.-E., A.K.G., Y.L., R.L.K., D.D.B., E.A.G., S.C.R., J.C., J.T.Y.) and Orthopedic Surgery (G.H.W., D.E.P., D.J.M., A.S.R., C.S.R.), Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for K.M. Jules-Elysee: juleselyseek@hss.edu.Departments of Anesthesiology (K.M.J.-E., A.K.G., Y.L., R.L.K., D.D.B., E.A.G., S.C.R., J.C., J.T.Y.) and Orthopedic Surgery (G.H.W., D.E.P., D.J.M., A.S.R., C.S.R.), Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for K.M. Jules-Elysee: juleselyseek@hss.edu.Departments of Anesthesiology (K.M.J.-E., A.K.G., Y.L., R.L.K., D.D.B., E.A.G., S.C.R., J.C., J.T.Y.) and Orthopedic Surgery (G.H.W., D.E.P., D.J.M., A.S.R., C.S.R.), Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for K.M. Jules-Elysee: juleselyseek@hss.edu.Departments of Anesthesiology (K.M.J.-E., A.K.G., Y.L., R.L.K., D.D.B., E.A.G., S.C.R., J.C., J.T.Y.) and Orthopedic Surgery (G.H.W., D.E.P., D.J.M., A.S.R., C.S.R.), Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for K.M. Jules-Elysee: juleselyseek@hss.edu.Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, George Washington University, 950 New Hampshire Avenue, 5th Floor, Washington, DC 20052. E-mail address: yanma@gwu.edu.Departments of Anesthesiology (K.M.J.-E., A.K.G., Y.L., R.L.K., D.D.B., E.A.G., S.C.R., J.C., J.T.Y.) and Orthopedic Surgery (G.H.W., D.E.P., D.J.M., A.S.R., C.S.R.), Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for K.M. Jules-Elysee: juleselyseek@hss.edu.Departments of Anesthesiology (K.M.J.-E., A.K.G., Y.L., R.L.K., D.D.B., E.A.G., S.C.R., J.C., J.T.Y.) and Orthopedic Surgery (G.H.W., D.E.P., D.J.M., A.S.R., C.S.R.), Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for K.M. Jules-Elysee: juleselyseek@hss.edu.Departments of Anesthesiology (K.M.J.-E., A.K.G., Y.L., R.L.K., D.D.B., E.A.G., S.C.R., J.C., J.T.Y.) and Orthopedic Surgery (G.H.W., D.E.P., D.J.M., A.S.R., C.S.R.), Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for K.M. Jules-Elysee: juleselyseek@hss.edu.

Pub Type(s)

Journal Article
Randomized Controlled Trial

Language

eng

PubMed ID

25995489

Citation

Jules-Elysee, Kethy M., et al. "Patient-controlled Epidural Analgesia or Multimodal Pain Regimen With Periarticular Injection After Total Hip Arthroplasty: a Randomized, Double-blind, Placebo-controlled Study." The Journal of Bone and Joint Surgery. American Volume, vol. 97, no. 10, 2015, pp. 789-98.
Jules-Elysee KM, Goon AK, Westrich GH, et al. Patient-controlled epidural analgesia or multimodal pain regimen with periarticular injection after total hip arthroplasty: a randomized, double-blind, placebo-controlled study. J Bone Joint Surg Am. 2015;97(10):789-98.
Jules-Elysee, K. M., Goon, A. K., Westrich, G. H., Padgett, D. E., Mayman, D. J., Ranawat, A. S., Ranawat, C. S., Lin, Y., Kahn, R. L., Bhagat, D. D., Goytizolo, E. A., Ma, Y., Reid, S. C., Curren, J., & YaDeau, J. T. (2015). Patient-controlled epidural analgesia or multimodal pain regimen with periarticular injection after total hip arthroplasty: a randomized, double-blind, placebo-controlled study. The Journal of Bone and Joint Surgery. American Volume, 97(10), 789-98. https://doi.org/10.2106/JBJS.N.00698
Jules-Elysee KM, et al. Patient-controlled Epidural Analgesia or Multimodal Pain Regimen With Periarticular Injection After Total Hip Arthroplasty: a Randomized, Double-blind, Placebo-controlled Study. J Bone Joint Surg Am. 2015 May 20;97(10):789-98. PubMed PMID: 25995489.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Patient-controlled epidural analgesia or multimodal pain regimen with periarticular injection after total hip arthroplasty: a randomized, double-blind, placebo-controlled study. AU - Jules-Elysee,Kethy M, AU - Goon,Amanda K, AU - Westrich,Geoffrey H, AU - Padgett,Douglas E, AU - Mayman,David J, AU - Ranawat,Amar S, AU - Ranawat,Chitranjan S, AU - Lin,Yi, AU - Kahn,Richard L, AU - Bhagat,Devan D, AU - Goytizolo,Enrique A, AU - Ma,Yan, AU - Reid,Shane C, AU - Curren,Jodie, AU - YaDeau,Jacques T, PY - 2015/5/22/entrez PY - 2015/5/23/pubmed PY - 2015/7/28/medline SP - 789 EP - 98 JF - The Journal of bone and joint surgery. American volume JO - J Bone Joint Surg Am VL - 97 IS - 10 N2 - BACKGROUND: The optimal postoperative analgesia after primary total hip arthroplasty remains in question. This randomized, double-blind, placebo-controlled study compared the use of patient-controlled epidural analgesia (PCEA) with use of a multimodal pain regimen including periarticular injection (PAI). We hypothesized that PAI would lead to earlier readiness for discharge, decreased opioid consumption, and lower pain scores. METHODS: Forty-one patients received PAI, and forty-three patients received PCEA. Preoperatively, both groups were administered dexamethasone (6 mg, orally). The PAI group received a clonidine patch and sustained-release oxycodone (10 mg), while the PCEA group had placebo. Both groups received combined spinal-epidural anesthesia and used an epidural pain pump postoperatively; the PAI group had normal saline solution, while the PCEA group had bupivacaine and hydromorphone. The primary outcome, readiness for discharge, required the discontinuation of the epidural, a pain score of <4 (numeric rating scale) without parenteral narcotics, normal eating, minimal nausea, urination without a catheter, a dry surgical wound, no acute medical problems, and the ability to independently transfer and walk 12.2 m (40 ft). RESULTS: The mean time to readiness for discharge (and standard deviation) was 2.4 ± 0.7 days (PAI) compared with 2.3 ± 0.8 days (PCEA) (p = 0.86). The mean length of stay was 3.0 ± 0.8 days (PAI) compared with 3.1 ± 0.7 days (PCEA) (p = 0.46). A significant mean difference in pain score of 0.74 with ambulation (p = 0.01; 95% confidence interval [CI], 0.18 to 1.31) and 0.80 during physical therapy (p = 0.03; 95% CI, 0.09 to 1.51) favored the PCEA group. The mean opioid consumption (oral morphine equivalents in milligrams) was significantly higher in the PAI group on postoperative day 0 (43 ± 21 compared with 28 ± 23; p = 0.002) and postoperative days 0 through 2 (136 ± 59 compared with 90 ± 79; p = 0.004). Opioid-Related Symptom Distress Scale (ORSDS) composite scores for severity and bothersomeness as well as scores for nausea, vomiting, and itchiness were significantly higher in the PCEA group (p < 0.05). Quality of Recovery-40 scores and patient satisfaction were similar. CONCLUSIONS: PAI did not decrease the time to discharge and was associated with higher pain scores and greater opioid consumption but lower ORSDS scores compared with PCEA. The choice for analgesic regimen may depend on a particular patient's threshold for pain and the potential side effects. SN - 1535-1386 UR - https://www.unboundmedicine.com/medline/citation/25995489/Patient_controlled_epidural_analgesia_or_multimodal_pain_regimen_with_periarticular_injection_after_total_hip_arthroplasty:_a_randomized_double_blind_placebo_controlled_study_ L2 - http://dx.doi.org/10.2106/JBJS.N.00698 DB - PRIME DP - Unbound Medicine ER -