Running head: IV TYLENOL USE IN POST OPERATIVE ANALGESIA
IV Tylenol Use in Post Operative Analgesia
Randall Morris, April Schmidt, Michelle Semmes, Mary Shull & Sara Quainoo
N312
Duke University School of Nursing
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IV TYLENOL USE IN POST OPERATIVE ANALGESIA
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IV Tylenol Use in Postoperative Analgesia
Introduction
Postoperative pain results in suffering and can lead to multiple physiological and
psychological consequences such as splinting, decreased gastrointestinal mobility, and delayed
ambulation leading to increased length of stay. Multimodal analgesia, utilizing non-opioid
analgesics, is one approach to decrease opioid consumption and improve postoperative analgesia.
The use of multimodal analgesic techniques may result in reduced frequency of opioid-related
adverse effects, more effective postoperative pain relief, diminished opioid consumption, and
increased patient satisfaction (Smith, 2011). Intravenous Tylenol is a safe and tolerable
analgesic with the potential to decrease opioid consumption making it an attractive choice in
postoperative pain management (Groudine & Fossum, 2011). The goal of this research utilization
project is to answer the question, “In adult surgical patients (P), does the use of IV Tylenol (I),
compared to not using IV Tylenol (C), result in less opioid consumption (O) during the first 48
hours of the postoperative period (T)?” (Written by Sara, April, and Michelle, Edited by Mary
and Randall)
Methods
See Appendix A
Analysis
Ten studies were reviewed, and while measurement tools varied, each study showed that
the administration of IV acetaminophen decreased the need for postoperative opioid
consumption in adult surgical patients. A 2011 study examined the use of IV acetaminophen and
its role in decreasing opioid consumption after major orthopedic joint replacement surgery. The
study measured pain intensity differences over 24 hours, and the need for rescue medication.
Pain intensity differences were statistically significant in favor of IV acetaminophen compared
with placebo (Sinatra, et al., 2011). Also in 2011, a randomized double blind, placebo controlled
clinical trial performed in 76 women undergoing abdominal hysterectomy examined the
analgesic effect of preoperative acetaminophen on opioid consumption, pain scores, and side
effects in patients receiving an elective abdominal hysterectomy. The results showed a thirty
percent decrease in hydromorphone consumption in the group that received IV acetaminophen
during general anesthesia (Moon, Lee, Lee, & Moon, 2011). A double-blinded RCT involving
IV TYLENOL USE IN POST OPERATIVE ANALGESIA
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124 adult female patients undergoing robot-assisted endoscopic thyroidectomies found that the
group which received paracetamol had significantly lower pain scores within the first 24
postoperative hours (Hong, Kim, Chung, Yun, & Kill, 2010). Another RCT, which studied 90
adult female patients undergoing total abdominal hysterectomy, showed pain scores in the first
24 hours of the postoperative period to be significantly less in the two groups receiving
paracetamol than in the placebo group. Morphine consumption was reduced in the study groups
as well (Arici, Gurbet, Turker, Yavascaoglu, & Sahin, 2009). A double-blind, randomized study
examined 99 patients who were given IV propacetamol 2g or IM morphine 10mg or a placebo
following surgical removal of third molar teeth. The response to propacetamol was faster and
stronger then morphine on first administration and required less rescue opioid medication than
the placebo group (Van Aken, Thys, Veekman, & Buerkle, 2004). A double-blind, randomized
study comparing effectiveness of non-opioid analgesics for postoperative pain in 80 patients
following lumbar microdiscectomy found that VAS pain scores were low in all
groups. Paracetamol VAS scores were not significantly lower then the scores of those in the
placebo group (Grundmann, Wornle, Biedler, Kreuer, Wrobel, & Wilhelm. 2006). A systematic
review of 16 prospective RCT journal articles, published from 2005 through 2010 in 9 countries,
comparing the effects of IV acetaminophen vs. either an active comparator or placebo in adult
patients that received general, regional, sedation, or local anesthesia modalities, were reviewed
using the Jadad Scale to assess quality of the RCTs. In 12 of 14 of the placebo-controlled RCTs,
it was observed that those receiving IV acetaminophen had improved analgesia (Marcario &
Royal, 2011). Another systematic search of 36 RCTs with a cumulative total of 3896 patients,
assessed efficacy of a single dose of IV paracetamol, with co-administration of opioids, in adult
and child postoperative pain relief and intensity. Secondary endpoint analysis focused on the
mean difference in a decreased intervention effect from opioid usage. Only 6 of 36 studies
described the volume of patients that needed opioid rescue medication. Combined results showed
that those receiving placebo required a mean of 1.3 mg more opioid rescue medication than those
who received IV paracetamol (McNicol, et. al., 2011). A single-blind controlled study was
reviewed which sampled 40 adult patients undergoing complex, major abdominal or pelvic
surgery who were randomly determined to receive either IV paracetamol or placebo in
conjunction with IV meperidine. Outcomes were measured in the first 24 hours of the
postoperative period by meperidine consumption and mean pain scores, resulting in significantly
IV TYLENOL USE IN POST OPERATIVE ANALGESIA
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less consumption of IV meperidine in the group that received IV paracetamol (Memis, et al.,
2010). Finally, a randomized, double blind, placebo-controlled study, with parallel groups,
studied 76 adult patients undergoing elective tonsillectomy to investigate the efficacy, safety, and
opioid sparing effects of IV paracetamol during the first 24 hours of the postoperative period.
The primary measurement tool was the need for rescue medication (meperidine). Seventy-one
percent of patients who received IV paracetamol did not need meperidine and expressed greater
satisfaction with pain control (Atef & Fawaz, 2008). Based on the reviewed RCTs and
systematic reviews, there is strong evidence to support the hypothesis that the use of IV Tylenol
in adult surgical patients in the first 48-hours of the post operative period reduces the
consumption of opioids, when compared to placebo. (Written by group)
Implementation plan
Based on the review of the literature, there is a strong recommendation for IV
acetaminophen use intraoperatively to decrease opioid consumption. As a result, a practice
change will be implemented at Duke University Medical Center over a six-month period to
include intraoperative administration of 1 gram of IV acetaminophen during the maintenance
phase of anesthesia to adult surgical patients. A change team will be formed and will meet
weekly. The team leader will give a presentation during the first meeting on the research
findings; as well as the onset, peak, duration, adverse effects, contraindications, and benefits of
the drug. During the second weekly change team meeting, a key points sheet will be developed.
Information will be disseminated to the anesthesia staff at grand rounds, which is a weekly
anesthesia staff meeting where evidence-based research is discussed. The key points sheets will
be handed out to those in attendance and emailed to all members of the anesthesia team. Posters
promoting the use of IV acetaminophen will be exhibited near medication stations and in the
anesthesia break room. Weekly updates will be posted with statistics regarding usage and goals
for the next week. The updates will be discussed at weekly change team meetings, as well as
weekly grand rounds. (Written by Michelle and April)
Environment for change
In order to assess the environment for change, during the second week, the change team
will administer a questionnaire to the staff to assess their feelings about the change (see
IV TYLENOL USE IN POST OPERATIVE ANALGESIA
Appendix B). The clinical expertise and preferences of the staff will be considered, including
the discussion of an option to administer the IV acetaminophen at a different stage of the
anesthesia process (Moon, Lee, Lee, & Moon, 2011). Acetaminophen is a commonly used drug
for patients of all ages, religions, and cultures; therefore few anticipated cultural or religious
objections are expected. Patients with any level of liver dysfunction, however, will not be
candidates to receive IV acetaminophen intraoperatively during the initial phase of
implementation. Resources for implementing the change will jointly be drawn from the budgets
of the Departments of Anesthesia, Nursing, and Pharmacy. Marketing costs associated with the
change will come from the budget of each department to provide the specialized education for
their own personnel. (Written by Mary)
Change team
A multidisciplinary change team will be created to ensure effective implementation. The
team members will consist of a pharmacist, two anesthesiologists, and two CRNAs. The
pharmacist will ensure that there is an adequate supply of IV acetaminophen at all times.
Anesthesia providers will be the members of the health team administering the IV
acetaminophen. It is critical to gain their support, as well as educate them on the appropriate
dose and timing of administration. The members of this team must be stakeholders within their
departments to ensure critical support of the change. (Sara, Michelle, April and Mary)
Outcomes will be measured on a long-term basis, by the anesthesia review nurse. This
nurse will be trained to assess consumption of IV opioids during the first 48-hours of the
postoperative period (Memis, et al., 2010) as part of the routine chart review. The anesthesia
review nurse will not be a member of the change team to decrease the chance for bias in data
collection. All collected data will be objective data from the patients’ charts related to opioid
administration and pain responses recorded by bedside nurses. These results will be reported in
the weekly grand rounds meeting in order to further support the change implementation. Six
months following the implementation of the IV acetaminophen perioperatively, a second
questionnaire (Appendix C) will be administered to the staff in order to reevaluate their
perspectives of efficacy of the use of IV acetaminophen. The validity and reliability of the
questionnaires will be ensured through anonymous responses. (Written by Mary)
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IV TYLENOL USE IN POST OPERATIVE ANALGESIA
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Change Strategy
Objectives
Method/ plan
Increase
availability of IV
acetaminophen to
the OR setting.
Initial goal:
availability for
75% of adult
surgical cases
Responsibility
CRNA will assess Pharmacist and
quantity needed.
CRNA team leader
Four weeks prior
to implementation
date, pharmacy
will order an
adequate supply
of IV
acetaminophen
and stock this in
the OR with
current standard
drugs
Increase use of
Inform
CRNAs/
IV Tylenol to
Anesthesia
Anesthesiologists
50% of cases in
providers of the
which there are
research findings;
no
as well as the
contraindications. onset, peak,
duration, adverse
effects,
contraindications,
and benefits of
the drug on
patient outcomes.
(Written by Sara, edited by group)
Completion
Date
8/24/12
Measurable
outcomes
Supply of IV
acetaminophen was
consistently greater
than the quantity
needed for 75% of
adult surgical cases.
There were no IV
acetaminophen
shortages in the first
six months of
implementation.
12/10/12
A quality
improvement form
will be provided for
every case and the
anesthesia provider
will document if IV
Tylenol has been
administered or not.
Percentage of usage
will be calculated
weekly and reports
will be provided.
Resources/Budget/Timeline
Resources needed for the implementation of the use of IV acetaminophen perioperatively
include the drug itself, administration supplies, education and marketing materials for each
department, costs of labor time for the change team, as well as the staff as they are educated on
the practice change. According to a July 19, 2010 DukeHealth.org video transcript of surgery at
Duke, it was estimated that “more than 30,000 surgeries are performed each year” at Duke
Medical Center (Sowers, 2010). Our change strategy will realize increases in IV Tylenol
availability for 75% of the surgeries performed annually at Duke. Budgeting will occur on a
quarterly basis at a rate of approximately 5,600 surgeries quarterly with secondary goal to
IV TYLENOL USE IN POST OPERATIVE ANALGESIA
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increase use of IV acetaminophen in up to 50% of surgical cases with no contraindications.
According to a June 2011 University of Utah Hospitals and Clinics Pharmacy Bulletin, the
average wholesale price (AWP) for IV Tylenol “is $309.60 for 100 mL vials in packages of 24,
or $12.90 for each single-use 100 mL vial” (Healthcare Utah, 2011). Staffing costs will be billed
at the discipline specific hourly wage accrual rate to account for the Change Team membership
(Appendix D). The six-month implementation timeline (Appendix E) will allow all departments
adequate time to train their staff and incorporate the practice change into their own practice.
(Written by Randall)
IV TYLENOL USE IN POST OPERATIVE ANALGESIA
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References
Arici, S., Gurbet, A., Turker, G., Yavascaoglu, B., & Sahin, S. (2009). Preemptive analgesic
effects of intravenous paracetamol in total abdominal hysterectomy. Agri, 21(2), 54-61.
Atef, A., & Fawaz, A. (2008). Intravenous paracetamol is highly effective in pain treatment after
tonsillectomy in adults. European Archives of Otorhinolaryngology, 265(3), 351-355.
Groudine, S., & Fossum, S. (2011). Use of intravenous acetaminophen in the treatment of
postoperative pain. J Perianesth Nurs, 26(2), 74-80.
Grundmann, U., Wornle, C., Biedler, A., Kreuer, S., Wrobel, M., & Wilhelm, W. (2006). The
efficacy of the non-opioid analgesics Parecoxib, Paracetamol, and Metamizol for
postoperative pain relief after lumbar microdiscectomy. Anesthesia and Analgesia, 103,
217-222.
Hong, J. Y., Kim, W. O., Chung, W. Y., Yun, J. S., & Kil, H. K. (2010). Paracetamol reduces
postoperative pain and resuce analgesic demand after robot-assisted endoscopic
thyroidectomy by the transaxillary approach. World J Surg, 34(3), 521-526.
Marcario, A., & Royal, M. (2011). A literature review of randomized clinical trials of
intravenous acetaminophen (Paracetamol) for acute postoperative pain. Pain Practice,
11(3), 290-296.
McNicol, E., Tzortzopoulou, A., Cepeda, M., Francia, M., Farhat, T., & Schumann, R. (2011).
Single -dose intravenous Paracetamol or Propracetamol for prevention or treatment of
postoperative pain: A systematic review and meta-analysis. British Journal of
Anaesthesia, 106(6), 764-765.
IV TYLENOL USE IN POST OPERATIVE ANALGESIA
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Memis, D., Inal, M., Kavalci, G., Sezer, A., & Sut, N. (2010). Intravenous paracetamol reduced
the use of opioids, extubation time, and opioid-related adverse effects after major surgery
in intensive care unit. Journal of Critical Care, 25(3), 458-462.
Moon, Y. E., Lee, Y. K., Lee, J., & Moon, D. E. (2011). The effects of preoperative intravenous
acetaminophen in patients undergoing abdominal hysterectomy. Arch Gynecol Obstet,
284(6), 1455-1460.
Sinatra, R. S., Jahr, J. S., Reynolds, L., Groudine, S. B., Royal, M. A., Breitmeyer, J. B., &
Viscusi, E. R. (2011). Intravenous acetaminophen for pain after major orthopedic
surgery. Pain Practice.
Smith, H. S. (2011). Perioperative intravenous acetaminophen and NSAIDs. Pain Med, 12(6),
961-981.
Sowers, K. (COO). (2008). Your Surgery at Duke Medicine [Marketing Video]. Video March 17,
2012, posted to dukehealth.org Web site: http://www.dukehealth.org/health_library/
video/your_surgery_at_duke_medicine/article_view
Van Aken, H., Thys, L., Veekman, L., & Buerkle, H. (2004). Assessing analgesia in single and
repeated administrations of propacetamol for postoperative pain: Comparison with
morphine after dental surgery. Anesthesia and Analgesia, 98, 159-165.
IV TYLENOL USE IN POST OPERATIVE ANALGESIA
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Appendix A: Methods
A search using PubMed, Google Scholar, CINAHL, the National Library of Sciences via
the FDA Biosciences Library, and the website www.ofirmev.com was performed using a
combination of specific search terms to yield free access to full-text meta-analysis and
integrative research reviews. Search terms included: “acetaminophen”; “analgesics, nonsteroidal”; “pain, postoperative management”; “analgesics, non-narcotic”; “anti-inflammatory
agents, non-steroidal”; “IV acetaminophen”; “opioids”; “IV Tylenol”; “placebo”; “reduced
opioid AND postoperative”; “IV Tylenol compared to placebo”; “IV acetaminophen AND
opioids”; and “meta-analysis”. In addition, reference lists from articles retrieved and articles
identified on the www.ofirmev.com website were searched to determine if they satisfied our
PICOT research question. Results were culled by each team member during the search process
based on the presence of the following inclusion criteria: adult surgical patients, IV Tylenol use
as opposed to other routes of administration, measured opioid consumption, and articles less than
10 years old. Articles were excluded if they met the following criteria: non-surgical population,
non-adult population, articles not available in the English language, non-human studies, and
articles not available in full text. Search results yielded less than 25 integrative reviews and very
few meta-analyses that were deemed to include the key elements of our PICOT and inclusion
criteria. Most data relied upon in our analysis included randomized control trials (RCTs). A
review of the meta-analyses available revealed that the authors were not able to pool efficacy
results across the research articles because of uncontrolled variations in the variables including
dosing regimen and primary endpoint pain scores. (Written by Randall, Edited by Group)
IV TYLENOL USE IN POST OPERATIVE ANALGESIA
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Appendix B: Pre-implementation questionnaire
This questionnaire, related to IV acetaminophen, is to be submitted anonymously to the labeled
box in the OR staff lounge.
1) How often do you administer IV acetaminophen intraoperatively as part of your pain
management regimen?
2) If evidence was presented showing the benefit of using IV acetaminophen, would you be
willing to use it?
3) If not, why not?
4) What are the barriers to using IV acetaminophen?
IV TYLENOL USE IN POST OPERATIVE ANALGESIA
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Appendix C: Post-implementation Questionnaire
This questionnaire, related to IV acetaminophen, is to be submitted anonymously to the labeled
box in the OR staff lounge.
1) How often do you administer IV acetaminophen intraoperatively as part of your pain
management regimen?
2) Do you believe evidence (both published literature and your own experience) is sufficient to
include IV acetaminophen in your practice?
3) If not, why not?
4) What are the barriers to using IV acetaminophen?
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Appendix D: Budget
PROGRAM ITEM
FY 2013,
FY 2013
FY2013
FY2013
1st Qtr
2nd Qtr
3rd Qtr
4th Qtr.
EXPENSES:
Personnel costs (salary and benefits at hourly rate)
 Clinical Pharmacist
 Anesthesiologist (2)
 CRNAs (2)
Total Personnel Costs
$1,322.46
$3,461.54
$12,047.77
$16,831.77
Duke Medical Center Surgery and Nursing Department
Marketing Activities
 Posters
 Flyers
Total Marketing Activities
Supplies
 IV Tylenol for 5,600 Quarterly Surgeries
Total Supplies
Staff Education
 15 minute training for each OR staff member
$200
$100
$300
$72,240
$72,240
$2,103.36
$91,475.13
TOTAL EXPENSES
REVENUE
TOTAL REVENUE
(Written by Mary)
$0
IV TYLENOL USE IN POST OPERATIVE ANALGESIA
Appendix E: Timeline
Task
Completion Date
First weekly change team
7/2/12
meeting: Present evidence to
change team
Second weekly change team
7/9/12
meeting: Development of key
points sheet for anesthesia
staff
Distribution of key points
7/16/12
sheet to staff at grand rounds
Distribution of pre-
7/13/12
implementation
questionnaire
Pre-implementation
Due: 7/20/12
7/23/12
questionnaires reviewed by
change team
Training will be completed by
8/17/12
departments related to
dosage, administration,
timing, etc.
Posters and administration
reminders with published “go
8/20/12
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IV TYLENOL USE IN POST OPERATIVE ANALGESIA
live” date will be posted in
OR lounge and near
medication sources
Pharmacy will obtain, stock
8/24/12
and barcode IV
acetaminophen for OR use
with supply for 75% of adult
surgical cases
“Go live” date for pilot
9/3/12
implementation
Evaluation of weekly
Weekly: 9/10/12 through
administration and opioid
12/10/12
consumption data
Data collection by anesthesia
9/3/12 through 12/10/12
review nurse
Implementation goal: IV
12/10/12
acetaminophen
administration in at least 50%
of adult surgical cases
Distribution of post-
12/10/12
implementation
questionnaire
Evaluation of postimplementation
Due 12/16/12
12/17/12
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IV TYLENOL USE IN POST OPERATIVE ANALGESIA
questionnaire
Presentation of findings to
12/28/12
OR staff and hospital
administration
Change team meeting to
evaluate process and discuss
need for process
improvements and/or more
widespread implementation
(Written by Mary)
1/7/13
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