Multimodal Pain Management Regimen in Upper Extremity Trauma - A Randomized Controlled Blinded Study
Julian Zangrilli, DO1; Nura Gouda, BS2; Mark Wang, MD2; Pedro K Beredjiklian, MD2; Michael Rivlin, MD2
1Jefferson Health, Stratford, NJ, 2Rothman Institute, Philadelphia, PA
Management of perioperative pain can significantly affect a patient's perspective on their overall outcome. Improvements in pain control as well as reduced opioid use and side effects are seen when a multimodal combination regimen is used. The aim of this study is to determine how well these regimens control postoperative pain levels in elective upper extremity trauma cases and whether they effect functional levels in patients postoperatively during the bone healing process. We hypothesize that multimodal pain management will lower pain levels, opioid use and improve function compared to traditional therapy.
Materials & Methods
In this randomized, controlled, surgeon blinded study, we evaluated postoperative pain in patients undergoing elective distal radius fracture surgery. The control group received a preoperative regional block and postoperative Oxycodone and Tylenol for pain control. The treatment group received a preoperative regional block with both pre and postoperative dosing of Pregabalin, Celebrex, and Acetaminophen, with Oxycodone added to the postoperative regimen for the first 3 days. Outcomes were measured at post-op day 1, 3, 7 and weeks 2, 6 and 12. Data collected included Oxycodone pill counts, VAS scores, Quick Dash, Pain Anxiety Symptom Scale, workers comp and work status. Surgeon evaluation took place at 2, 6 and 12 weeks including X-ray, ROM, and grip/strength measurements.
There were 40 patients enrolled in the study. The control group had 21 patients while the multimodal pain regimen group had 19. The pain control in the first 24 hours was equivalent in both groups and comparable at 3 and 7 days as well as at later time points. Oxycodone pill use was almost double in the control group in the first 24 hours (average 9 vs. 5 pills, control vs. multimodal groups respectively). However, at 2 and 6 weeks the control group used less narcotics compared to the multimodal group. One patient in the control group had nonunion of the fractures while none in the multimodal group.
Early postoperative opioid use is less in patients with multimodal pain management protocol. Pain control is equivalent in both groups by patient rating. However, increased use of opioids in seen in the multimodal group after the multimodal regimen is discontinued.
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