A massive database analysis has confirmed the suspicions of thousands of practicing anesthesiologists the world over: Multimodal analgesia for joint arthroplasty is, indeed, a good thing. Data from more than 1.5 million patients demonstrated that the most tried and true medications provide the biggest bang for the buck when it comes to maximizing pain control while minimizing complications.
“Multimodal pain management has been heralded for years because it may be associated with improved pain management and reduced opiate consumption,” said Stavros G. Memtsoudis, MD, PhD, the director of critical care services and a senior scientist at the Hospital for Special Surgery, in New York City. “But we wanted to take it one step further. We wanted to know if the number and type of analgesic modes are associated with reduced complications, opioid prescriptions and resource utilization.”
To help answer these questions, Dr. Memtsoudis and his colleagues turned to Premier Perspective, a database comprising surgical information gathered from 546 hospitals nationwide. Limiting searches between 2006 and 2016, the researchers found a total of 512,393 hip arthroplasties and 1,028,069 knee arthroplasties. They considered a variety of analgesic modes, including opioids, peripheral nerve blocks, acetaminophen, steroids, gabapentin/pregabalin, nonsteroidal anti-inflammatory drugs (NSAIDs), cyclooxygenase-2 (COX-2) inhibitors and ketamine. Groups were categorized as either “opioids only” as well as one, two or more than two additional analgesic modes.
Although database studies are not without their shortcomings, the investigators believe they provide an accurate view of real-world clinical scenarios. “We read clinical studies—and they’re good studies—but when you have just a limited number of patients and they’re being performed at a single, specialized institution, what does it mean for a community hospital?” Dr. Memtsoudis said in an interview with Anesthesiology News.
“One criticism of big database studies is that there are confounding factors that can’t be controlled for,” he continued. “That may be true, but they also have a lot of benefits. This study includes 500-plus hospitals in different settings, and the data set does not exclude patients based on a set of contrived exclusion criteria. It’s not an artificial environment.”
Reporting in a recent issue of Anesthesiology (2018;128[5]:891-902), the investigators revealed that 85.6% of patients (n=1,318,165) received multimodal analgesia. In multivariable models, adding analgesic modes was associated with stepwise positive effects.
“So when you added one mode to the opioids, we saw a small effect,” he explained. “When you added two, the effect got bigger, and by the time you added the third one, it grew even more. We believe that’s a marker of true effect. Because when you have this sort of dose relationship, it underlines the quality of the data and the quality of the model.”
Indeed, the analysis revealed that total hip arthroplasty patients receiving more than two modes of analgesia experienced 19% fewer respiratory complications (odds ratio [OR], 0.81; 95% CI, 0.70-0.94), 26% fewer gastrointestinal complications (OR, 0.74; 95% CI, 0.65-0.84), an 18.5% decrease in opioid prescriptions (95% CI, –19.7% to –17.2%; 205 vs. 300 overall median oral morphine equivalents), and a 12.1% decrease in length of stay (95% CI, –12.8% to –11.5%; two vs. three median days) compared with patients who received opioids only (all P<0.05). Similar patterns were revealed in patients who underwent total knee arthroplasty.
“We chose knee and hip arthroplasty patients because they’re two of the fastest-growing surgeries in the U.S., and they tend to be very homogeneous groups of patients as well,” Dr. Memtsoudis said.
Finally, the researchers investigated which medications had the most significant effect on outcomes. “Clinicians will sometimes throw all sorts of things at patients, even though there may not be good evidence that any of those medications or interventions belong in a multimodal pain regimen,” he added. NSAIDs and COX-2 inhibitors seemed to be the most effective modalities, with the greatest attendant reduction in opioid prescriptions and complication risk. Using a peripheral nerve block also was found to be effective in reducing complications and opioid prescriptions.
“These are generic medications,” he said. “They’re not expensive; they’ve been around for a long time; and they can be utilized by everyone. It’s interesting that some of the more expensive and novel drugs out there really made little difference.”
Despite the strength of these findings, the researchers were quick to point out that the study does not indicate which combinations of analgesic approaches are most effective, an undertaking that would require a far more complicated analysis. Nevertheless, that did not stop Dr. Memtsoudis from supporting the continued—but cautious—use of opioids as an integral part of multimodal therapy. “While multimodal therapy is safe, all these medications have their own risks and side effects—it’s not just opioids,” he said.
“That’s why I always caution to not throw the baby out with the bathwater, because opioids have a legitimate role to play in pain management. I don’t think we should be trying to eliminate them altogether. Instead, I caution moderation when it comes to use of these agents.”
Nabil Elkassabany, MD, an assistant professor of anesthesiology and critical care and the director of orthopedic anesthesia at the University of Pennsylvania, in Philadelphia, commented on the study, noting that database studies shine a different light on clinical practice. “The nice thing about this big data research is that it informs clinical decision making and health policy,” Dr. Elkassabany said. “I think that every other institution that’s using multimodal analgesia, whether it’s after major joint arthroplasty or any other surgical procedure, has seen and sensed a lot of improvement in their own outcomes. But I don’t know if anyone has looked at these outcomes formally, in a real-world manner, as was done here by Dr. Memtsoudis and his colleagues.”
And yet, Dr. Elkassabany noted that barriers to implementation of multimodal analgesia include the cost of some of the newer medications, which may prevent its adoption at some institutions. “However, studies such as this one can put things in perspective and show that it doesn’t all come down to nickel-and-diming every drug, and that multimodal analgesia can improve utilization of health care resources. If you look at things from the bigger perspective, multimodal analgesia makes a lot of sense, and studies like this will encourage many institutions to adopt a multimodal-based approach.”
—Michael Vlessides
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