Monday, January 2, 2012

Must We Use IV Paracetamol/Acetaminophen?

I've yet to be terribly impressed with the "new" pain control options available to clinicians these days.  We've got tapentadol (Nucynta), which works just about as well as ibuprofen.  We've got companies working on a purified hydrocodone derivative that's 10 times stronger and equally more dependence forming.  And then we have intravenous paracetamol/acetaminophen.

So, it works.  Studies, like this one, show it's reasonably effective and has a minimal side effect profile - at least compared to the mild incidence of nausea seen with IV morphine.  It's slightly faster acting, achieves more reliable plasma levels than oral paracetamol/acetaminophen, and it's presumably as safe - although the safety of any intravenous drug is compromised due to extravasation risks and potential administration errors.  Oral paracetamol/acetaminophen bills a patient a few dollars while IV administration bills around a hundred, and I continue to wonder whether these sorts of "innovations" are worthwhile advances in pain control outside of extremely narrow indications.  I believe we now stock this and intravenous ibuprofen at our hospital - and goodness knows I've never seen anyone use them.  While relief in suffering is undoubtedly one of our most important roles in healthcare, we have to weigh the few moments of physical suffering against the long-term consequences/suffering of the hospital bills that may be passed along to our patients.

Anyone have a favorable experience with these new non-narcotic medications?

"Intravenous paracetamol versus morphine for renal colic in the emergency department: a randomised double-blind controlled trial"
http://www.ncbi.nlm.nih.gov/pubmed/22186009

8 comments:

  1. so, is tapentadol supposed to be the new Toradol, since ketorolac is on permanent hiatus (so it seems)?

    Thanks for the great work you do here!

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  2. Tapentadol is supposedly for use for chronic pain in the outpatient setting. I haven't seen or heard of a ketorolac shortage - just the upcoming etomidate shortage. I generally avoid ketorolac when possible, as most studies show ibuprofen is equivalent.

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  3. In Australia IV paracetamol is (at least in NBM post-op land) the drug de rigueur. We use LOTS of it (though it's a lot cheaper than that here - about $6 a dose - it's still about 1000x the price of oral).

    We've had multiple reports in our hospital of peri- or post-infusion hypotension though (especially from ICU with their arterial lines and continuous monitoring). We suspected partially due to the manitol content of the IV, however at least one patient repeated the same event post conversion to NG route.

    In summary - it has it's uses, but toxicity/side effect wise we're starting to get a bit jumpy around here...

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  4. That's a great comment that wasn't emphasized enough in my review - paracetamol is difficult to maintain in IV suspension and requires a lot of additives - leading to those infusion-related issues as mentioned. Are you using it mostly for pain? Or for fever (if you're giving it IV in the ICU)?

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  5. We have not had ketorolac for almost 6 weeks. Etomidate is also out to lunch, as is lidocaine, and a list of about 40 other agents that our pharmacy just can't get. Maybe it is a regional thing? Regardless, thanks for the update!

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  6. Almost exclusively for pain. It's not licensed for fever here, and although I'm sure there's some leakage the vast majority of what we use is being used to treat pain.

    Of course given that we're talking about ICU patients here they may also be septic and febrile...

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  7. We began using this a good bit in the OR right after I began an anesthesia rotation. We saw amazing results in the reduction of fentanyl usage (~75% reduction) and post-operative narcotic requirements in the PACU. Patients woke up more quickly and cleanly, without bucking (the subjective perception of 10+ CRNAs). But then again, I wasn't paying the bill for the IV acetaminophen, there was no comparison with an equivalent dose of PO acetaminophen, and this doesn't necessarily translate into the ED.

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  8. Hmm - what about rectal acetaminophen while they're in the PACU prior to awakening? Obviously, not every surgical patient will have the PR route available, but it's certainly cheaper!

    Decreasing narcotic usage is still a surrogate measure for a patient-oriented outcome - it probably speaks to something of value, particularly if you're seeing adverse events requiring intervention from narcotic usage in the PACU. Or, as you say, with the ventilator bucking, whether that leads to decreased patient satisfaction/dangerous extubation conditions.

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