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Impact of intravenous acetaminophen on multimodal pain management after total knee arthroplasty: a double-blinded randomized controlled trial
ESSKA Academy. Tsukada S. May 11, 2018; 218084
Sachiyuki Tsukada
Sachiyuki Tsukada
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Abstract
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Objectives: Pain after total knee arthroplasty (TKA) is severe. Although multimodal pain management including periarticular multi-drug injection can provide excellent pain relief during the early postoperative period of TKA, the pain score has been reported to become worse after 24 hours postoperatively. We conducted a randomized, double-blind, placebo-controlled trial to investigate the effectiveness of intravenous acetaminophen on multimodal pain management for TKA.

Methods: We recruited patients undergoing TKA between January 2016 and December 2016 from a single orthopedic clinic. Participants were randomly assigned on a 1:1 basis to receive either intravenous acetaminophen or intravenous normal saline as placebo. We ensured that the patients and surgical teams were blinded to the results of random allocation during the study period. In the intravenous acetaminophen group, we administered 1000 mg of intravenous acetaminophen [100 mL] at 6-hour intervals (23:00 on the day of TKA, at 05:00, 11:00, 17:00, and 23:00 one day after TKA, at 05:00, 11:00, 17:00, and 23:00 two days after TKA, and at 05:00 three days after TKA). In the normal saline group (placebo group), we administered 100 mL of normal saline in the same interval as described for intravenous acetaminophen group. We routinely performed intraoperative periarticular multi-drug injection including methylprednisolone 40 mg [1mL], 7.5 mg/mL ropivacaine [40 mL], 10 mg/mL morphine hydrochloride hydrate [0.8 mL], 1.0 mg/mL epinephrine [0.3 mL], and 50 mg of ketoprofen [2.5 mL]. At the time of administration of study drugs (intravenous acetaminophen or placebo), we evaluated pain score at rest evaluated by visual analog scale (VAS) score as the primary outcome of this study. VAS score during activity and complication rate were evaluated as the secondary outcomes.

Results: A total of 67 patients were randomly assigned to intravenous acetaminophen group (n = 32) or placebo group (n = 35). The VAS score at rest at 17:00 one day after TKA was significantly better in the intravenous acetaminophen group than the placebo group (15.3 ± 17.0 mm versus 26.8 ± 19.0 mm, respectively, P = 0.013). The VAS score during activity at one day after TKA was significantly better in the intravenous acetaminophen group than the placebo group (26.3 ± 17.6 mm versus 38.8 ± 27.0 mm, respectively, P = 0.032).There were no significant differences in the rate of complications, including impaired liver function.

Conclusions: The VAS score at rest at 17:00 one day after TKA was lower in the intravenous acetaminophen group than the placebo group for patients treated with multimodal pain management including periarticular multi-drug injection.

Keywords:
knee arthroplasty; pain management; acetaminophen
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