Hospital Pharmacy - May 2017 - 368

368
patients undergoing hemorrhoidectomy or bunionectomy.17,18
Published studies have been conducted in a variety of other
patient populations undergoing surgical procedures including hernia repair, breast augmentation, and laparoscopic
urology.19-21 Studies in patients undergoing joint arthroplasty
have reported variable findings relative to the effect of liposomal bupivacaine on pain control and utilization of opioid
pain medications.22-25 There are limited number of studies
that have specifically assessed the use of liposomal bupivacaine by a single surgeon in patients undergoing orthopedic
knee or hip procedures.26-32 Evaluation of patients having
undergone procedures by a single surgeon minimizes potential confounding effects of variable surgical technique.
Furthermore, prior studies of liposomal bupivacaine use in
joint arthroplasty have been limited by small sample sizes,
minimal community hospital sites, and lack of measurements
related to physical therapy milestones such as ambulation.
The objective of this study was to retrospectively evaluate
the use of liposomal bupivacaine in an ethnically diverse,
large sample of patients undergoing orthopedic knee or hip
procedures performed by a single surgeon in a community
hospital setting. The study assessed the association between
the use of liposomal bupivacaine and concurrent opioid analgesic medication use, postoperative pain scores, length of
hospital stay, ambulation, and range of motion.

Methods
This study involved retrospective chart review of patients
who underwent joint arthroplasty from August 1, 2012, to
July 31, 2014, at a 450-bed community hospital in a large
metropolitan city in the United States. The Pharmacy and
Therapeutics (P&T) committee at this community hospital
approved the inclusion of liposomal bupivacaine to the formulary but restricted its use to only one individual surgeon
for orthopedic procedures related to the knee, hip, or shoulder over the period of time from August 2013 to July 2014.
Prior to the addition of liposomal bupivacaine to the formulary, patients undergoing these orthopedic procedures
received an intraoperative dose of bupivacaine hydrochloride 0.5% with epinephrine, morphine, and ketorolac. The
study compared a cohort of patients who underwent orthopedic procedures of the knee or hip and received intraoperative
liposomal bupivacaine 266 mg (20 mL) into the joint, with a
historical cohort of patients seen by the same surgeon who
did not receive liposomal bupivacaine. All patients in both
groups were at least 18 years old and were undergoing an
orthopedic knee or hip procedure. Patients who were concurrently enrolled in a sponsored pain study were excluded from
participation. This study was approved by the hospital's
institutional review board.
A report was generated from the pharmacy that provided
a list of all patients with a charge for liposomal bupivacaine
who had an orthopedic knee or hip procedure during a 1-year
time period from August 2013 to July 2014. This group was

Hospital Pharmacy 52(5)
defined as the study group. A separate report was generated
from hospital admission data that included all patients who
were seen by the same surgeon and who had an orthopedic
knee or hip procedure during the 1-year period prior to addition of liposomal bupivacaine to the formulary (August 2012
to July 2013). This second group of patients served as the
historical control group. Results are presented comparing the
study group with the control group for knee patients and hip
patients, respectively.
The primary clinical outcomes of interest were concurrent
opioid analgesic medication use during the 72-hour postoperative time period and postoperative pain score. Additional
clinical outcomes of interest included time to first rescue
analgesic medication, length of hospitalization, ambulation
distance in all patients, range of motion only for patients who
underwent knee procedures, and opioid-induced adverse
events. The total consumption of intravenous or oral opioids
for the 72-hour postoperative period was converted to morphine equivalents using online conversion calculators.33,34
Time to first rescue pain medication was calculated by comparing the time of first opioid administration that was documented in the electronic medication administration record to
the time noted for the end of the surgical procedure. As part
of the regular standard of practice, nurses performed pain
assessments at least every 4 hours during the postoperative
period, and these values were documented on the electronic
medical flowsheet. Patients were asked to rate their pain on a
numeric rating scale where 0 indicated no pain and 10 indicated the worst pain possible. Average pain scores were calculated from these recorded pain scores immediately after
surgery, the first 24-hour period (0-24 hours), second 24-hour
period (25-48 hours), third 24-hour period (49-72 hours),
and total postoperative period (0-72 hours). Length of hospital stay reported in days was calculated based on the difference between date of admission and date of discharge.
Finally, average distance ambulated for knee and hip patients
were calculated from data physical therapists recorded in the
medical charts on the day of surgery and for the subsequent
3 postoperative days. Range of motion values (extension and
flexion) were also reported by physical therapists for knee
patients on postoperative days 1 to 3. Physician and nurse
daily progress notes, along with daily vital signs, were
reviewed for any documentation of adverse events including
respiratory depression, hypotension, nausea, constipation, or
itching.
Chi-square test was used to compare study and control
groups for categorical variables like gender and race. Student
t test was used to compare study and control groups for differences in means for the following variables: total opioid
consumption during the 72-hour postoperative time period,
average pain scores, time to first opioid rescue pain medication, length of stay, distance ambulated, range of motion, and
opioid-induced adverse events. For the nonparametric variables of length of stay and time to first rescue pain medication, median and interquartile range are reported and were



Table of Contents for the Digital Edition of Hospital Pharmacy - May 2017

Editorial, For Sale: FDA Priority Review Vouchers
Current FDA-Related Drug Information; Approvals, Submission, and Important Labeling Changes for US Marketed Pharmaceuticals
Summaries of Safety Labeling Changes Approved by the FDA: Boxed Warnings
ISMP Adverse Drug Reactions: Levofloxacin-Induced Neuroexcitation and Hallucinations Statin-Induced Muscle Rupture Mefloquine-Induced Rhabdomyolysis Methimazole-Induced
Critical Care Pharmacist Market Perceptions: Comparison of Critical Care Program Directors and Directors of Pharmacy
Capecitabine, Oxaliplatin, and Bevacizumab (BCapOx) Regimen for Metastatic Colorectal Cancer
Clinical Pharmacy Discharge Counseling Service and the Impact on Readmission Rates in High-Risk Patients
Mannitol Prescribing Practices With Cisplatin Before and After an Educational Newsletter Intervention
Pharmacists’ Knowledge of the Cost of Laboratory Testing
Adverse Drug Reaction Reporting Practices Among United Arab Emirates Pharmacists and Prescribers
Postoperative Pain Management With Liposomal Bupivacaine in Patients Undergoing Orthopedic Knee and Hip Arthroplasty at a Community Hospital
Formulary Drug Reviews
Hospital Pharmacy - May 2017 - 317
Hospital Pharmacy - May 2017 - 318
Hospital Pharmacy - May 2017 - 319
Hospital Pharmacy - May 2017 - 320
Hospital Pharmacy - May 2017 - 321
Hospital Pharmacy - May 2017 - 322
Hospital Pharmacy - May 2017 - 323
Hospital Pharmacy - May 2017 - Editorial, For Sale: FDA Priority Review Vouchers
Hospital Pharmacy - May 2017 - 325
Hospital Pharmacy - May 2017 - Current FDA-Related Drug Information; Approvals, Submission, and Important Labeling Changes for US Marketed Pharmaceuticals
Hospital Pharmacy - May 2017 - Summaries of Safety Labeling Changes Approved by the FDA: Boxed Warnings
Hospital Pharmacy - May 2017 - 328
Hospital Pharmacy - May 2017 - 329
Hospital Pharmacy - May 2017 - ISMP Adverse Drug Reactions: Levofloxacin-Induced Neuroexcitation and Hallucinations Statin-Induced Muscle Rupture Mefloquine-Induced Rhabdomyolysis Methimazole-Induced
Hospital Pharmacy - May 2017 - 331
Hospital Pharmacy - May 2017 - 332
Hospital Pharmacy - May 2017 - 333
Hospital Pharmacy - May 2017 - Critical Care Pharmacist Market Perceptions: Comparison of Critical Care Program Directors and Directors of Pharmacy
Hospital Pharmacy - May 2017 - 335
Hospital Pharmacy - May 2017 - 336
Hospital Pharmacy - May 2017 - 337
Hospital Pharmacy - May 2017 - 338
Hospital Pharmacy - May 2017 - 339
Hospital Pharmacy - May 2017 - 340
Hospital Pharmacy - May 2017 - Capecitabine, Oxaliplatin, and Bevacizumab (BCapOx) Regimen for Metastatic Colorectal Cancer
Hospital Pharmacy - May 2017 - 342
Hospital Pharmacy - May 2017 - 343
Hospital Pharmacy - May 2017 - 344
Hospital Pharmacy - May 2017 - 345
Hospital Pharmacy - May 2017 - 346
Hospital Pharmacy - May 2017 - 347
Hospital Pharmacy - May 2017 - Clinical Pharmacy Discharge Counseling Service and the Impact on Readmission Rates in High-Risk Patients
Hospital Pharmacy - May 2017 - 349
Hospital Pharmacy - May 2017 - 350
Hospital Pharmacy - May 2017 - 351
Hospital Pharmacy - May 2017 - 352
Hospital Pharmacy - May 2017 - Mannitol Prescribing Practices With Cisplatin Before and After an Educational Newsletter Intervention
Hospital Pharmacy - May 2017 - 354
Hospital Pharmacy - May 2017 - 355
Hospital Pharmacy - May 2017 - 356
Hospital Pharmacy - May 2017 - Pharmacists’ Knowledge of the Cost of Laboratory Testing
Hospital Pharmacy - May 2017 - 358
Hospital Pharmacy - May 2017 - 359
Hospital Pharmacy - May 2017 - 360
Hospital Pharmacy - May 2017 - Adverse Drug Reaction Reporting Practices Among United Arab Emirates Pharmacists and Prescribers
Hospital Pharmacy - May 2017 - 362
Hospital Pharmacy - May 2017 - 363
Hospital Pharmacy - May 2017 - 364
Hospital Pharmacy - May 2017 - 365
Hospital Pharmacy - May 2017 - 366
Hospital Pharmacy - May 2017 - Postoperative Pain Management With Liposomal Bupivacaine in Patients Undergoing Orthopedic Knee and Hip Arthroplasty at a Community Hospital
Hospital Pharmacy - May 2017 - 368
Hospital Pharmacy - May 2017 - 369
Hospital Pharmacy - May 2017 - 370
Hospital Pharmacy - May 2017 - 371
Hospital Pharmacy - May 2017 - 372
Hospital Pharmacy - May 2017 - 373
Hospital Pharmacy - May 2017 - Formulary Drug Reviews
Hospital Pharmacy - May 2017 - 375
Hospital Pharmacy - May 2017 - 376
Hospital Pharmacy - May 2017 - 377
Hospital Pharmacy - May 2017 - 378
Hospital Pharmacy - May 2017 - 379
Hospital Pharmacy - May 2017 - 380
Hospital Pharmacy - May 2017 - 381
Hospital Pharmacy - May 2017 - 382
Hospital Pharmacy - May 2017 - 383
Hospital Pharmacy - May 2017 - 384
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