Regional anesthesia is a safe and effective modality of perioperative pain control in patients undergoing ambulatory hand procedures.1-10 Often, as the regional block wears off, patients experience a rebound pain effect that can be challenging to manage.
We sought to determine if an organized, multimodal approach in patients undergoing thumb carpometacarpal (CMC) arthroplasty or open reduction and internal fixation (ORIF) of distal radius fractures would provide better postoperative pain control. We hypothesized that this approach would significantly reduce postoperative pain and the need for narcotic pain medication compared with PRN dosing of oxycodone/acetaminophen alone.11-14
MATERIALS AND METHODS
Our study was approved by our Institutional Review Board. Informed consent was obtained from each patient. Patients presenting for elective thumb CMC arthroplasty or ORIF of the distal radius were screened for inclusion in a prospective, randomized study. Inclusion criteria included patients aged 18 to 65 years who could provide informed consent. Patients with chronic pain syndromes, long-term narcotic usage, chronic medical conditions precluding the use of opiates or nonsteroidal anti-inflammatory drugs (NSAIDs), and those who did not have a complete sensory and motor block postoperatively were excluded.
Patients were randomly divided into 1 of 4 study arms. Randomization was performed via sealed envelopes, which were opened in the recovery area when postoperative prescriptions were written. The group distribution was as follows: Group 1, Percocet 5 mg/325 mg alone (control); Group 2, oxycodone 5 mg, acetaminophen 325 mg administered separately; Group 3, oxycodone 5 mg, acetaminophen 325 mg, and oxycodone SR (OxyContin) 10 mg; and Group 4, oxycodone 5 mg, acetaminophen 325 mg, and ketorolac (Toradol) 10 mg (Table 1). Patients in the control group were instructed to take 1 or 2 tablets every 4 to 6 hours as needed for pain. Patients in the 3 experimental groups were given detailed instructions regarding when and how to take their medications. All patients were instructed to take 650 mg of acetaminophen every 6 hours. Patients were provided a sliding scale to assist in dosing their opioid medications according to their numeric pain score (NPS) (Table 2). Group 2 patients were given oxycodone 10 mg in the postanesthesia care unit (PACU) and instructed to take oxycodone 10 mg with acetaminophen 650 mg every 6 hours on a scheduled basis until their block wore off, then dose themselves using the NPS.
Table 1. Patient Groups
Group | Anesthesia | Pain Medications |
1 (standard treatment) | Brachial plexus block | Percocet (oxycodone and acetaminophen) 5-10 mg every 4-6 hours as needed for pain. |
2 | Brachial plexus block | 1. Oxycodone 0-15 mg every 4-6 hours as needed for pain based on pain scale score. 2. Tylenol (Acetaminophen) 650 mg every 6 hours, scheduled. |
3 | Brachial plexus block | 1. Oxycodone 0-15 mg every 4-6 hours as needed for pain based on numeric pain scale. 2. Tylenol (Acetaminophen) 650 mg every 6 hours, scheduled. 3. OxyContin (oxycodone sustained release) 10 mg twice a day, scheduled. |
4 | Brachial plexus block | 1. Oxycodone 0-15 mg every 4-6 hours as needed for pain based on pain scale score. 2. Tylenol (Acetaminophen) 650 mg every 6 hours, scheduled. 3. Toradol (Ketorolac) 10mg every 6 hours, scheduled. |
Table 2. Sliding Scale for Pain Control in the Experimental Groups
Pain Score | Oxycodone Dose |
0-3 | 5 mg (1 tablet) |
4-7 | 10 mg (2 tablets) |
8-10 | 15 mg (3 tablets) |
Group 3 patients were given oxycodone 10 mg in the PACU and instructed to take oxycodone 10 mg with acetaminophen 650 mg every 6 hours and OxyContin 10 mg every 12 hours on a scheduled basis until their block wore off, then dose themselves using NPS. Group 4 patients were given oxycodone 10 mg postoperatively and ketorolac 30 mg intravenously in the PACU and instructed to take oxycodone 10 mg, acetaminophen 650 mg, and ketorolac 10 mg every 6 hours on a scheduled basis until their block wore off, then dose themselves using the NPS.
Patients were provided with a journal and asked to record their medication usage, NPS, and any adverse effects (nausea, vomiting, and uncontrolled pain were specifically mentioned) or complications for 5 days after their procedure. We also attempted to contact patients by telephone on each of the 5 days after their procedure to remind them to complete their logs. They were asked specifically if they were having difficulty with their medications. They were also asked specifically about nausea, vomiting, and over-sedation. If patients requested additional medication to help treat their pain, they were instructed to add an over-the-counter NSAID of their choice based on the label’s suggested dosing.
Continue to: All patients received a supraclavicular...