• Anesthesia related pain management strategies and 24 hour postoperative outcomes in traumatic tibia fracture patients

      Virts, Elena Victorovna; Storr, Carla L. (2015)
      Background: Pain management Pain management research is uncommon in trauma patients with tibia fracture who undergo surgery within 24 hours of admission. Acute intoxication is a risk factor for orthopedic trauma; however, whether pain management outcome differs between sober and intoxicated patients at admission is unknown. Purpose: Three commonly used anesthesia-related pain management (ARPM) strategies (Benzo, administration of preoperative benzodiazepines within 90 minutes of anesthesia start; Opioid, intraoperative administration opioids by the end of surgery; and Combo, a combination of both strategies) were examined for postoperative outcomes (pain intensity, time to achieve postanesthesia care unit [PACU] discharge criteria, total postoperative opioid consumption, and frequency of postoperative nausea and vomiting [PONV]). The outcomes associated with these ARPM strategies were evaluated according to whether a patient was sober or intoxicated at admission. Methods: A chart review of 206 adult trauma patients admitted for tibia fractures in 2007 though 2009 provided information on personal characteristics and physical status, perioperative pain intensity, administration of analgesics and pharmacological adjuvants, frequencies of PONV, time required to achieve PACU discharge criteria, surgical and injury attributes, and alcohol intoxication on admission. A mixed effects model and linear and logistic regressions were used to examine the relationships between the ARPM strategies and outcomes. Results: Most patients (84%) received an ARPM strategy (Benzo, 30%; Opioid, 21%; Combo, 33%). A majority (83.5%) reported severe pain; one third experienced PONV. Postoperative opioid consumption (range, 3.75 to 336.88 mg of morphine) and time required to achieve PACU discharge criteria (range, 10 to 358 minutes) varied widely. All ARPM strategies were associated with higher pain ratings compared with control patients, without altering the time required to achieve PACU discharge criteria. All ARPM strategies decreased total opioid consumption up to 50%, but this effect was limited to the first four postoperative hours. Combo strategy reduced the occurrence of PONV, but higher pain ratings were reported. Intoxicated patients received the most benefit from Benzo strategy, whereas Opioid strategy was detrimental to them. Conclusion: Benzodiazepines are recommended for orthopedic trauma patients who are intoxicated on admission, whereas a combination strategy is more appropriate for patients prone to PONV.