Development of an NSAID decision tool for perioperative pain management in adult orthopaedic patients: a modified Delphi study

Authors

DOI:

https://doi.org/10.17159/2309-8309/2025/v24n3a%25

Keywords:

NSAIDs, decision tool, perioperative pain management, orthopaedic surgery, multimodal analgesia, Delphi consensus

Abstract

Background: Orthopaedic surgery is rated among the most painful of surgeries, leaving patients at risk of experiencing moderate to severe postoperative pain. A multimodal analgesic approach helps reduce opioid requirements, with nonsteroidal anti-inflammatory drugs (NSAIDs) playing a key role in this strategy, provided they are not contraindicated. However, only limited guidance exists for safe perioperative NSAID use in orthopaedic patients with comorbidities. The objective of the study was to achieve consensus on safe, short course (≤ 1 week) administration of NSAIDs in adult orthopaedic patients with comorbidities, and to convert the results into a decision tool to aid clinicians in safe perioperative NSAID administration.

Methods: A Delphi panel of 18 experienced orthopaedic surgeons, physicians and anaesthetists participated in a three-round Delphi process. The panel assessed 42 patient characteristics using a nine-point Likert scale in the first two rounds. After the second round, consensus was defined as ≥ 75% either ‘disagreeing’ (Likert scale 1–3) or ‘agreeing’ (Likert scale 7–9) that NSAIDs ± proton pump inhibitors (PPIs) could or could not be administered safely. Characteristics without consensus by round 2 moved to round 3, where subspecialty experts conducted a rapid review of the literature. Consensus in this round required ≥ 75% support for expert recommendations.

Results: All panel members participated in the first and third rounds, with 16 in the second. After the second round, consensus was achieved for 24 of 42 patient characteristics. However, in preparation for the third round, three characteristics which had achieved consensus after round 2 were added to the pool of characteristics to be considered by subspeciality experts, resulting in 21 proceeding to the third round. In round 3, consensus for all remaining subspeciality expert recommendations was achieved and an NSAID decision tool with guidance in safe perioperative NSAIDs use ± PPIs was subsequently developed for the 42 patient characteristics.

Conclusion: This study establishes a consensus on short-term NSAID administration in adult orthopaedic patients with comorbidities, offering a decision tool to guide clinicians in safely incorporating NSAIDs into perioperative pain management strategies.

Level of evidence: 5

Author Biographies

Ulla Plenge, University of Cape Town

Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa

Maritz Laubscher, University of Cape Town

Orthopaedic Research Unit (ORU), Division of Orthopaedic Surgery, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa

Marc B Nortje, University of Cape Town

Orthopaedic Research Unit (ORU), Division of Orthopaedic Surgery, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa

Sithombo Maqungo, University of Cape Town

Orthopaedic Research Unit (ORU), Division of Orthopaedic Surgery, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
Head of Clinical Unit: Orthopaedic Trauma

Thomas Hilton, University of Cape Town

Orthopaedic Research Unit (ORU), Division of Orthopaedic Surgery, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa

Robert Dunn , University of Cape Town

Orthopaedic Research Unit (ORU), Division of Orthopaedic Surgery, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
Head: Division of Orthopaedic Surgery

Stephen JL Roche, University of Cape Town

Orthopaedic Research Unit (ORU), Division of Orthopaedic Surgery, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa

Marcin B Nejthardt, University of Cape Town

Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
Head of Clinical Unit

Alma de Vaal, University of Cape Town

Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa

Sibylle Eickhoff , Life Vincent Pallotti Hospital

Private practice anaesthetist, Life Vincent Pallotti Hospital, Cape Town, South Africa
Private practice anaesthetist, Life Kingsbury Hospital, Cape Town, South Africa

Ettienne Coetzee, University of Cape Town

Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
Specialist anaesthetist, Red Cross War Memorial Children’s Hospital, Cape Town, South Africa

Owen S Porrill, University of Cape Town

Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
Private practice anaesthetist, Life Vincent Pallotti Hospital, Cape Town, South Africa
7 Private practice anaesthetist, Life Kingsbury Hospital, Cape Town, South Africa

Luis FM Pelaez, University of Cape Town

Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
Head of Clinical Unit: Cardiothoracic Anaesthesia

Vernon J Louw, University of Cape Town

Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
Chair and Head: Division of Clinical Haematology

Bridget Hodkinson, University of Cape Town

Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
Chair and Head of Division: Rheumatology

Mashiko Setshedi, University of Cape Town

Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
Chair and Head of Medicine

Peter J Raubenheimer, University of Cape Town

Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
Head of Division: General Internal Medicine

Nicola Wearne, University of Cape Town

Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
Head of Division: Nephrology and Hypertension

Ashley Chin, University of Cape Town

Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
Head of Division: Pacing and Electrophysiology, Cardiac Clinic

Romy Parker, University of Cape Town

Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
Head: Pain Management

Bruce M Biccard, University of Cape Town

Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
Second Chair

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Published

2025-08-15

Issue

Vol. 24 No. 3 (2025)

Section

Trauma

License

Copyright (c) 2025 Ulla Plenge, Associate Professor Maritz Laubscher, Dr Marc B Nortje, Professor Sithombo Maqungo, Dr Thomas Hilton, Professor Robert Dunn    , Professor Stephen James Lawrence Roche, Associate Professor Marcin Bartosz Nejthardt, Dr Alma de Vaal, Dr Sibylle Eickhoff , Dr Ettienne Coetzee, Dr Owen Scott Porrill, Dr Luis Felipe Montoya Pelaez, Professor Vernon Johan Louw, Professor Bridget Hodkinson, Professor Mashiko Setshedi, Professor Peter J Raubenheimer, Associate Professor Nicola Wearne, Associate Professor Ashley Chin, Professor Romy Parker, Professor Bruce M. Biccard

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