Use of Intravenous Acetaminophen to Control Pain and Improve Outcomes in Thoracic Surgery

Mehul Patel, Naveen Jayakumar, Kian Bagheri, Kaveh Bagheri and Ara S. Klijian

Department of Thoracic Surgery, Sharp and Scripps Hospitals, USA
Department of Critical Care and Pulmonary Medicine, Sharp Grossmont Hospital, USA
Department of Internal Medicine, Eisenhower Health, Rancho Mirage, CA, USA
University of Michigan, USA

^*Correspondance to: Ara S. Klijian 

 PDF  Full Text DOI: 10.25107/2474-1647.2105

Abstract

Objective: The primary objective was to assess whether the addition of IV acetaminophen (Ofirmev) to standard opioid and ketorolac pain relievers for thoracotomy, Video Assisted Thoracic Surgery (VATS), and Awake Video Assisted Thoracic Surgery (AVATS) patients reduced ICU length of stay (LOS), time to extubation, hospital LOS, or opioid use. The secondary outcomes evaluated were reintubation, patient satisfaction and pain index. We also looked at the occurrence of ileus, pneumonia, Deep Venous Thrombosis (DVT), Pulmonary Emboli (PE), Urinary Tract Infection (UTI), Atrial Fibrillation (AF), IV phlebitis, and development of delirium.Methods: This was a retrospective cohort study conducted in adults who had undergone traditional thoracotomies, VATS, and AVATS procedures between 2012 to 2018 at two academic centers. We evaluated 199 cases. There were 98 patients who received only opioids and ketorolac (OK) and 101 patients who received IV acetaminophen in conjunction with opioid and ketorolac and (OK+A). Patients who did not receive IV Tylenol did so do to lack of availability of IV Tylenol at location/ time of surgery. Treatment groups were not randomized. All procedures were performed by a single surgeon.Results: Analysis included all 199 patients. The average LOS, in days, for the OK+A group was 2.33 (95% CI 2.16 - 2.49) after VATS, 1.53 (95% CI 1.37 - 1.69) after AVATS, and 3.57 (95% CI 3.31 - 3.82) after thoracotomy, respectively. In contrast, for the comparator group receiving traditional pain relievers, mean LOS values were 2.95 (95% CI 2.80 - 3.10), 2.45 (95% CI 2.17 - 2.73), and 5.16 (95% CI 4.64 - 5.677). The average time to extubation (hours) for these procedures in the OK+A group was 0.33 (95% CI 0.15 - 0.52) for VATS and 1.30 (95% CI 0.94 - 1.66) for thoracotomy, versus, in the traditional group, 8.37 (95% CI 4.36 - 12.39) for VATS and 18.13 (95% CI 15.69 - 20.56) for thoracotomy. The average ICU LOS (in days) for the OK+A group was 0.51 (95% CI 0.42 - 0.60) for VATS, 0.36 (95% CI 0.25 - 0.46) for AVATS, and 1.47 (95% CI 1.34 - 1.60) for thoracotomy. In contrast, for the traditional group, the ICU LOS was 1.14 (95% CI 1.01 - 1.27) for VATS, 1.39 (95% CI 1.19 - 1.59) for AVATS, and 2.36 (95% CI 1.90 - 2.82) for thoracotomy. We saw a trend towards decreased opioid use in patients receiving IV acetaminophen compared to the traditional regimen.Conclusion: In this non-randomized cohort, addition of IV acetaminophen to traditional pain management with opioids and ketorolac for both thoracoscopic surgeries and open thoracotomy led to clinically significant decreases in the average hospital LOS, time to extubation, and ICU LOS. This effect was most marked in patients having AVATS. Integrating routine IV acetaminophen usage in patients undergoing thoracic surgery was associated with improved patient comfort and satisfaction, and helped improve compliance with incentive spirometry, earlier ambulation, and lower urinary catheter dependence. This would be expected to reduce complications such as pneumonia, DVT, PE, and UTI. The demonstrated reduced LOS should also translate to improved hospital cost saving.

Keywords

IV acetaminophen; Ofirmev; Thoracotomy; VATS; AVATS; Multimodal analgesia

Cite the article

Patel M, Jayakumar N, Bagheri K, Bagheri K, Klijian AS. Use of Intravenous Acetaminophen to Control Pain and Improve Outcomes in Thoracic Surgery. Clin Surg. 2018; 3: 2105.