Researchers found that when IV acetaminophen (APAP) was removed from the ambulatory surgical setting formulary, there was not an increase in post-anesthesia care unit length of stay (LOS), although postoperative pain might have been higher.1
The ASC routinely used IV APAP for all eye, ear, nose, or throat (EENT) procedures because providers thought the drug would improve recovery and decrease post-anesthesia care unit length of time.1
Although opioids were the primary analgesics for post-operative pain control, this changed in recent years due to opioids’ adverse effects of central nervous system and respiratory depression.1
“Usually after surgery, patients were given an opioid, like morphine, and those can be sedating,” says Asad Patanwala, PharmD, a researcher with the University of Arizona College of Pharmacy in Tucson.
The price of IV APAP doubled, bringing the total cost of analgesics with IV APAP to 15 times the cost of analgesics without it. The total cost of analgesics that included IV APAP was $15 vs. $1 for the non-APAP analgesics, Patanwala says.
Other adjunctive agents included oral APAP, lidocaine, ketorolac, and ketamine. Nonsteroidal anti-inflammatory agents and rectal APAP were not used.1
“These analgesics don’t cost a lot of money,” he says. “Only acetaminophen contributed to the cost.”
The pharmacy formulary committee, including pharmacists and other members, reviewed the use of IV APAP as part of ongoing efforts to improve cost-effectiveness.
“We had to remove the intravenous acetaminophen from the formulary in July 2014 due to an increase in the price of this medication,” says Moteb Khobrani, PharmD, a research scholar with the University of Arizona.
“In this circumstance, it was removed from the formulary because we didn’t think there was evidence to support its use,” Patanwala says.
“The physicians who used this medication argued that this medication would decrease length of stay and decrease the opioid consumption,” Khobrani says.
A literature review did not produce enough data to support the use of APAP for the purpose of reducing LOS, so researchers designed the retrospective cohort study to see if APAP did reduce LOS.
“It’s a good practice to evaluate what happens when you make a change, especially when there isn’t a lot of literature out there,” Patanwala says.
There were two groups of 87 patients who received an EENT procedure at the ASC. One group received the IV APAP and the other did not. The EENT population was chosen, in part, because it was the only population in which IV APAP was used routinely, from January 2014 until July 2014, when it was removed from the formulary.1
Also, the non-APAP group contained more patients with coronary artery disease, chronic obstructive pulmonary disease, and anxiety disorders than the APAP group. Most of the patients in the IV APAP group received a single dose of 1,000 mg APAP intravenously. The median length of stay was 66 minutes in the APAP group and 71 minutes in the non-APAP group.1
Researchers found that one reason the LOS was not lower with the IV APAP group was because using IV APAP did not lead to less opioid consumption. This belied the theory that APAP usage reduces opioid consumption, leading to decreased recovery time.1
“The study’s results showed that the non-use of acetaminophen did not influence length of stay. It was similar,” Patanwala says. “There did appear to be more pain without the intravenous acetaminophen, and that’s a meaningful finding.”
The increased pain could be the result of other pain agents not being optimized. “Some of the other agents were not being used to the extent they could have been used,” Patanwala notes.
“The only advice I’d give to centers, based on this data, is if you’re not using IV acetaminophen, it’s worth making sure patients are getting adequate amounts of other analgesics to make sure pain control does not decline,” Patanwala says.
Patients could receive an oral form of APAP before surgery to help keep pain levels lower, he adds.
REFERENCE
- Khobrani MA, Camamo JM, Patanwala AE. Effect of intravenous acetaminophen on post-anesthesia care unit length of stay, opioid consumption, pain, and analgesic drug costs after ambulatory surgery. P T 2017;42:125-139.
Researchers found that when IV acetaminophen was removed from the ambulatory surgical setting formulary, there was not an increase in post-anesthesia care unit length of stay, although postoperative pain might have been higher.
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