Opioids Administered Immediately Prior to TJA Surgery

We reviewed six studies that compared the influence of an opioid administered pre-emptively immediately prior to TJA to placebo on postoperative outcomes after TJA.[16–21] Five studies are high quality and one is moderate quality. Three studies evaluated transdermal fentanyl patches placed 10 – 12 hours prior to surgery, one study evaluated intramuscular morphine, one study evaluated oral morphine, and one study evaluated intravenous morphine. A very limited amount of meta-analyses was performed due to inconsistency in outcomes reported and the timepoints at which these outcomes were reported. 

            All six studies reported visual analogue pain scores (VAS) within 72 hours after TJA after administration of an opioid pre-emptively prior to TJA. Four of the high quality studies found that an opioid administered pre-emptively prior to surgery resulted in lower VAS scores within 72 hours after TJA compared to placebo.[16–19] Three of these studies evaluated transdermal fentanyl and the fourth study evaluated intramuscular morphine. The two remaining studies, which evaluated intravenous morphine and oral morphine, found no difference in VAS scores compared to placebo.[20,21]

All six studies evaluated opioid consumption within 72 hours after TJA. Five of the six studies found that administration of an opioid pre-emptively prior to TJA resulted in lower morphine consumption after TJA compared to placebo.[16,18–21] The other study found no difference in opioid consumption after TJA when comparing pre-emptive opioid administration to placebo.[17] Only one study evaluated range of motion after TJA and found no difference amongst patients who received a pre-emptive opioid prior to TJA compared to placebo.[16] Three studies included a direct meta-analysis with moderate heterogeneity found that patients who received an opioid preemptively prior to surgery had decreased opioid consumption compared to placebo (-1.51 standard mean difference; 95% confidence interval -2.37 to -0.64).

             Direct meta-analyses were performed to compare rates of nausea, vomiting, and urinary retention. The direct meta-analyses found no difference between patients who received a pre-emptive opioid prior to TJA and placebo in rates of nausea (0.88 relative risk; 95% confidence interval 0.62 to 1.25), vomiting (0.60 relative risk; 95% confidence interval 0.33 to 1.10), and urinary retention (1.08 relative risk; 95% confidence interval 0.34 to 3.40). Four studies evaluated sedation and respiratory depression and found no difference between pre-emptive opioids and placebo. [16,17,19,21]

             However, it is the opinion of the workgroup that when combined with other opioids administered during the perioperative period, such as intraoperatively or postoperatively, opioids administered prior to surgery may increase the risk of complications including respiratory depression and sedation.