Advances in Modern Medicine Through Evidence Based Practice

For the entire history of surgery, the quest to find a pain reliving agent that would not

only perform the job of alleviating pain, but also result in the best patient outcomes has

successful in some respects and troublesome in others. If you were to travel back in time and

discuss medicine with a surgeon in the 19th century, aspects of surgery that we take for granted

today would be absent in his practice. To ponder the leaps of innovation in the relative short

time of 200 years that we have achieved is nothing short of mind boggling. Today we stand with

high survival rates, lower chances of infections, and overall better medicinal practices than ever

before in history. With all the noted advances in modern medicine, it is not perfect; through trial,

error, and peer review, modern medicine can continue to evolve to accommodate for best patient

outcomes through evidence-based practice.

One of the examples of evidence-based practice involves the healing time and nonunion

rate of surgeries on bone (internal fixation and other corrective surgeries), in relation to what

medicines are given in the postoperative period. In a large study in which over 300,000 cases of

fractures were examined by a team of physicians, some of the major factors of bone nonunion

were identified. According to Steen (2016), “… the most powerful risk factor (for bone

nonunion) was use of nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids. Other pain

medications, such as opioids alone, and anticonvulsants, with or without benzodiazepines, were

moderately strong positive risk factors…” (pg 4). Patients that took NSAIDs or opioids in the

postoperative period were shown to have a positive correlation with a longer recovery time and

increased incidence of malunion or nonunion. This, in the cases of malunion or nonunion, likely

leads to another surgery which exposes the patient to all the risks that surgery entails. In all
cases, this leads to increased time until the patient is able to return to all of their regular activities

of daily life which is in itself a negative patient outcome.

As healthcare professionals, patient care and positive outcomes are of utmost importance

in all levels of care. Evidence-based practice is essential in finding solutions to result in better

patient care as well as positive patient outcomes.

A favorable solution

As mentioned previously, patients who took NSAIDs or opioids during their

postoperative recovery period had higher incidences of increased recovery time as well as

complications such as malunion and nonunion. It is scientifically proven that NSAIDs delay

bone healing, so it is required that an alternative solution be found to relieve postoperative

swelling in patients that have had surgeries to resolve broken bones. Promising advances are

being made regarding this very problem as evidenced by a 2018 study examining Ketorolac as an

alternative to other NSAIDs.

According to McDonald (2018),” In comparison when investigating time to union and

healing rates in femoral shaft and tibial shaft fractures, Donohue et al found ketorolac

administration had no effect on time to union or healing rates. Specifically, in the treatment of

fractures, time to healing and union rates are better in patients receiving ketorolac than other

nonsteroidal anti-inflammatory drugs (NSAIDs).” (pg 10). Although ketorolac is categorized as

an NSAID, it did not inhibit bone growth in that particular study. With those results, it seems

that the administration of ketorolac in patients that underwent surgery for broken bones

experienced the anti-inflammatory properties that NSAIDs provide without the negative bone

union inhibiting side effects.