Association of perioperative use of nonsteroidal anti-inflammatory drugs with postoperative myocardial infarction after total joint replacement.

BACKGROUND AND OBJECTIVES: Use of nonsteroidal anti-inflammatory drug (NSAIDs) analgesics is controversial because of cardiovascular risk, but perioperative use may be advantageous for total joint replacement. Thus, we performed this single-center observational cohort study to determine any association between NSAID use and postoperative myocardial infarction (POMI). METHODS: All patient admissions undergoing total hip or knee replacement between March 3, 2009, and September 1, 2010, were identified. Nonsteroidal anti-inflammatory drug use was identified. Postoperative myocardial infarction was defined as troponin I level greater than 0.1 ng/mL. Propensity scores were calculated to adjust for bias of receiving NSAIDs and troponin measurements. Propensity scores and other covariates were used in logistic regression to determine the independent association of NSAID use with POMI. RESULTS: Of the 10,873 arthroplasty admissions, 1518 (14%) had serial troponins measured, and 97 had a POMI (0.9%). Incidence of POMI was 0.8% for the 9,831 who received NSAIDs and 1.8% for the 1,042 (10%) admitted patients who did not receive NSAIDs with a risk difference of -1% with 95% confidence interval (CI) of -0.2% to -1.9%. The adjusted odds ratio (0.95; 95% CI, 0.5-1.8) and relative risk (0.95; 95% CI, 0.5-1.8) indicated that NSAIDs were not significantly associated with the risk of POMI. Mean duration of NSAID use was 3 days. Length of stay (98 versus 115 hours) was significantly reduced in the NSAID group. CONCLUSIONS: Brief perioperative use of NSAIDs was not associated with increased risk for myocardial infarction after total hip and knee replacement; it may provide benefit in length of stay.

A prospective survey of patient-controlled epidural analgesia with bupivacaine and clonidine after total hip replacement: a pre- and postchange comparison with bupivacaine and hydromorphone in 1,000 patients.

BACKGROUND AND OBJECTIVES: Patient-controlled epidural analgesia (PCEA) with bupivacaine and hydromorphone provides high quality analgesia after orthopedic surgery but is associated with a frequent incidence of opioid-related side effects (15%-30%). Epidural clonidine has a different side effect profile, but there are no large surveys documenting its use. We performed this prospective survey to evaluate analgesia and the side effect profile in total hip replacement patients before and after a systematic change from PCEA with bupivacaine/hydromorphone to bupivacaine/clonidine. METHODS: Five hundred consecutive patients received PCEA with 0.06% bupivacaine and hydromorphone (10 mcg/mL) as a previously described prechange control group. The standard analgesic regimen was then systematically changed to 0.06% bupivacaine and clonidine (1 mcg/mL) without changing the PCEA settings or other aspects of perioperative care, and 500 consecutive patients were included as a postchange group. All data were prospectively entered and then abstracted from the electronic medical record. Data collection included daily verbal pain scores (VPS), pruritus, nausea, hypotension, need for IV fluid boluses, sedation, and respiratory depression. An online survey to measure staff satisfaction with the changeover was sent to all participating surgeons, anesthesiologists, physical therapists, and physician's assistants. RESULTS: Patient characteristics were similar between groups. Most patients received central neuraxial anesthesia (99%). The clonidine group had lower VPS at rest (2.3 vs 3.7, P<0.001 with 95% confidence interval [CI] of difference of 1.4 [1.1, 1.7]) on POD0. The incidence of nausea was 10%-11% for clonidine and 13%-15% for hydromorphone. The incidence of pruritus was less with clonidine (1 vs 10%, P<0.01 with 95% CI of difference of 9% [6, 12]). However, the incidence of hypotension (20 vs 11%, P<0.001 with 95% CI of differences 9% [5, 14]) and IV fluid boluses was more frequent with clonidine (36 vs 19%, P<0.001 with 95% CI of differences of 16 [11, 12]). Sixty-five percent of staff completed the online survey, and 70% considered clonidine worse than hydromorphone. CONCLUSION: The systematic changeover from epidural hydromorphone to clonidine produced mixed results without obvious superiority. The VPS at rest was reduced only on postoperative day 0; pruritus was reduced, but hypotension was increased. On the basis of medical staff preference, we discontinued the systematic change and returned to our previous standard solution of bupivacaine and hydromorphone for PCEA after total hip replacement.

Prospective survey of patient-controlled epidural analgesia with bupivacaine and hydromorphone in 3736 postoperative orthopedic patients.

BACKGROUND AND OBJECTIVES: Patient-controlled epidural analgesia(PCEA) has been shown to be superior to intravenous patient-controlled analgesics (PCA) for postoperative analgesia after thoracic, abdominal, pelvic, and lower extremity surgery. However, it is unclear which opioid is optimal for PCEA. Hydromorphone has potential advantages, yet there are no data to establish its efficacy and safety. Thus, we prospectively monitored our patients receiving PCEA with bupivacaine combined with hydromorphone after orthopedic surgery. METHODS: All postoperative patients who received PCEA from March 1 to September 21, 2009, were included. Lumbar PCEA was initiated after central neuraxial anesthesia with 0.06% bupivacaine combined with hydromorphone 10 microg/mL. Initial settings were a bolus dose of 4 mL, lockout interval of 10 mins, and background infusion of 4 mL/hr. Patients were allowed oral analgesics, and meloxicam was routinely administered as an adjunct analgesic. Patients were evaluated twice a day at our Acute Pain Service department. Pain scores, adverse effects, and medications were entered prospectively into the electronic patient record. RESULTS: Verbal pain scores (0Y10) at rest were 3, 3, 3, and 2 on postoperative days 0 to 3. Verbal pain scores with activity were 4, 3, 3, and 3. Most adverse effects were modest to rare (15% pruritus, 10% hypotension,0.08% sedation, and 0% respiratory depression) with the exception of nausea (30%). There were no epidural hematomas or abscesses. Median duration of PCEA was 27 hrs. CONCLUSIONS: Patient-controlled epidural analgesia with bupivacaine and hydromorphone provides effective and safe postoperative analgesia for orthopedic surgery.