Multimodal pain management has become the standard of care following total hip and knee replacement. The advantages include decreasing opioid consumption and its associated side effects, facilitating earlier mobilization, and faster return to function. An effective rapid recovery protocol includes the use of multiple different types of medications targeting each area of the pain pathway, preemptive analgesia, regional nerve blockade, and local infiltration analgesia.
Key points
- •
Proactive, multimodal pain management in the setting of total joint arthroplasty allows for earlier mobilization and leads to enhanced rapid recovery and patient satisfaction.
- •
Minimizing opioid use is the hallmark of multimodal pain management, improving the targeting of all pain pathways while decreasing perioperative nausea and enhancing rapid participation with postoperative rehabilitation.
- •
Combined use of local periarticular anesthetic infiltration with avoidance of excessive soft tissue dissection and appropriate use of regional anesthesia improves patient satisfaction and pain control following total joint arthroplasty.
- •
Failure to control pain following total joint arthroplasty increases medical costs and risk of venous thromboembolism while prolonging overall recovery and length of stay.
Introduction
Adequate pain control is a prerequisite of rapid recovery total joint arthroplasty. Patient satisfaction is often linked to appropriate perioperative pain management. The involvement of the anesthesia team in the rapid recovery protocol is critical, with contributions to multimodal analgesia owed to enhanced regional anesthesia and neuraxial techniques. The arthroplasty surgeon and anesthesiologist should aim to capitalize on the most current techniques to achieve successful multimodal pain management.
Introduction
Adequate pain control is a prerequisite of rapid recovery total joint arthroplasty. Patient satisfaction is often linked to appropriate perioperative pain management. The involvement of the anesthesia team in the rapid recovery protocol is critical, with contributions to multimodal analgesia owed to enhanced regional anesthesia and neuraxial techniques. The arthroplasty surgeon and anesthesiologist should aim to capitalize on the most current techniques to achieve successful multimodal pain management.
Multimodal pain management
The philosophy of multimodal pain management in the setting of total joint replacement refers to the use of multiple types of medications delivered through many different routes with the goal of targeting all pain pathways simultaneously ( Fig. 1 ). This strategy reduces the undesired side effects of narcotic medications including nausea, vomiting, sedation, ileus, respiratory depression, and pruritus. The result is improved patient satisfaction and earlier mobilization.
Preemptive analgesia
Preemptive analgesia is one of the hallmarks of multimodal pain management. By addressing pain before making the incision, the process of sensitization and production of inflammatory chemicals is prevented. With the absence of nerve fiber sensitization, the patient’s pain threshold is effectively increased resulting in a decreased risk of chronic neuropathic pain and improved pain management.
Treating pain before surgery allows the patient to stay ahead of the pain, which ultimately improves the efficacy of the other modes of treatment. Throughout the postoperative and rehabilitation phases, taking pain medication prophylactically keeps pain to a minimum and avoids peaks of discomfort that may interfere with recovery ( Fig. 2 ).
Medications
Preemptive analgesic medications are typically administered in the preoperative holding area 1 to 2 hours before the procedure but may also be initiated days before surgery. These medications typically include nonsteroidal anti-inflammatory medications (NSAIDs), cyclooxygenase (COX)-2 inhibitors, gabapentinoids, and acetaminophen ( Table 1 ).
| Medication | Dose, mg | Route | Preoperative, h | Postoperative |
|---|---|---|---|---|
| Ketorolac | 15–30 | Oral/intravenous | 1–2 | 15–30 mg every 6 h |
| Celecoxib | 400 | Oral | 1–2 | 200 mg daily |
| Gabapentin | 300 | Oral | 1–2 | 300 mg × 1 after 24 h |
| Pregabalin | 75 | Oral | 1–2 | 75 mg × 1 after 12 h |
| Acetaminophen | 1000 | Oral/intravenous | 0–2 | 650 mg every 6 h |
COX-2 inhibitors are particularly attractive for total joint replacement patients because of their reduced risk of gastric and platelet effects compared with other traditional NSAIDs. These medications have been shown to improve pain scores in total knee arthroplasty (TKA) patients with less opioid consumption and improved range of motion when analyzed in multiple randomized control trials. However, in doses greater than 400 mg daily, COX-2 inhibitors increase the risk of cardiac events and should be used cautiously in patients with active cardiac disease.
Glucocorticoids, specifically dexamethasone and methylprednisolone, are beneficial in the role of preemptive analgesia by decreasing the postoperative inflammatory response. These medications are often given at the time of surgery by the anesthesiologist and work together as an adjuvant treatment to prolong analgesia while reducing nausea and vomiting. Furthermore, they have been used safely without increasing wound complications with short-term use.
One of the effects of preemptive analgesia is reducing narcotic consumption in the perioperative period. Although opioids still play a central role in controlling postoperative pain, reducing them improves patient satisfaction and curtails complications related to nausea, vomiting, ileus, respiratory depression, and cognitive dysfunction, especially in the elderly patient.
Related posts:
Orthopedic Clinics of North America
Patient Satisfaction After Total Knee Arthroplasty
Pediatric Perioperative Pain Management
The Importance of Optimizing Acute Pain in the Orthopedic Trauma Patient
Perioperative Pain Management in Pediatric Spine Surgery
Perioperative Pain Management for Upper Extremity Surgery
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
