title: Fewer postoperative fevers: an unexpected benefit of multimodal pain management?
abstract: BACKGROUND
  Elevated temperatures after total joint arthroplasty (TJA) are common and can be a source of anxiety both for the patient and the surgical team. Although such fevers rarely are caused by acute infection, many patients are subjected to extensive testing for elevated body temperature after surgery. We recently implemented a multimodal pain management regimen for TJA, which includes acetaminophen, pregabalin, and celecoxib or toradol, and because some of these medications have antipyrexic properties, it was speculated that this protocol might influence the frequency of postoperative pyrexia.
  
  
  OBJECTIVE
  The purpose of this study was to determine whether patients treated under this protocol were less likely to exhibit postoperative fever after primary TJA, compared with a historical control group, and whether they were less likely to receive postoperative testing as part of a fever workup.
  
  
  METHODS
  We compared 1484 primary TJAs in which pain was controlled primarily with opioid-based relief from July 2004 to December 2006 with 2417 procedures from July 2009 to December 2011 during which time multimodal agents were used. The same three surgeons were responsible for care in both of these cohorts. Oral temperature readings in the first 5 postoperative days (POD) were drawn from a review of medical records, which also were evaluated for fever workup tests, including urinalysis, urine culture, chest radiograph, and blood culture. Fever was defined by the presence of a temperature measurement over 38.5 °C. Patients having preoperative fever or postoperative fever starting later than POD 5 were excluded. Before surgery, there were no differences between the groups' temperature measurements.
  
  
  RESULTS
  Fewer patients developed fever in the multimodal analgesia group than in the control group (5% versus 25%, p < 0.001). Furthermore, fewer patients underwent workup for fever in the multimodal analgesia cohort (1.8% of patients undergoing 155 individual tests) compared with the control cohort (9.8% of patients undergoing 247 individual tests; p < 0.001).
  
  
  CONCLUSIONS
  In addition to fewer adverse effects and better pain control, the multimodal analgesia protocol has the hidden benefit of dampening the temperature response to the surgical insult of TJA. The decreased rate of postoperative fever avoids unnecessary anxiety for the patient and the treating team and reduces healthcare resource use occasioned by working up postoperative fever.
  
  
  METHODS
  Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
authors.affiliation: Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, The Sheridan Building, 125 S 9th Street, Suite 1000, Philadelphia, PA, 19107, USA.
authors.forename: Joseph A
authors.initials: JA
authors.lastname: Karam
authors.forename: Benjamin
authors.initials: B
authors.lastname: Zmistowski
authors.forename: Camilo
authors.initials: C
authors.lastname: Restrepo
authors.forename: William J
authors.initials: WJ
authors.lastname: Hozack
authors.forename: Javad
authors.initials: J
authors.lastname: Parvizi
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000700:Analgesics / Q000627:therapeutic use*; D058633:Antipyretics / Q000627:therapeutic use*; D019643:Arthroplasty, Replacement / Q000009:adverse effects*; D001833:Body Temperature Regulation / Q000187:drug effects; D004359:Drug Therapy, Combination; D005260:Female; D005334:Fever / Q000175:diagnosis / Q000209:etiology / Q000503:physiopathology / Q000517:prevention & control*; D006801:Humans; D008297:Male; D008875:Middle Aged; D059408:Pain Management / Q000379:methods*; D010149:Postoperative Pain / Q000175:diagnosis / Q000209:etiology / Q000517:prevention & control*; D012189:Retrospective Studies; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D000700:Analgesics; D058633:Antipyretics