⌚ Postoperative Pain Management

Tuesday, November 09, 2021 12:01:18 AM

Postoperative Pain Management

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Postoperative Pain Management - ICA Webinar

The most commonly practiced method for analgesia is a combination of NSAIDs and opioids, and while this has proven effective, the inclusion of opioids does predispose the patient to numerous side effects including nausea, vomiting, pruritus, sedation, constipation, and urinary retention. Nausea and vomiting occurred in Despite the effectiveness of this traditional analgesia combination, the addition of other non-opioid pharmaceutical agents has been proven to be more effective than NSAIDs and opioids alone. Both propacetamol and ketorolac were shown to be superior to morphine PCA alone in the management of postoperative pain following ELEA, yielding an earlier onset of analgesia.

When compared to each other, both propacetamol and ketorolac were similarly efficacious in lowering pain relief scores. Celecoxib was found to improve VAS pain scores and active ROM compared to the placebo, in addition to lowering opioid requirements. The risk of adverse cardiovascular effects is related to a reduction in prostacyclin synthesis secondary to COX-2 inhibition without a concomitant decrease in thromboxane synthesis, resulting in unopposed thromboxane-mediated platelet aggregation and vasoconstriction.

Similarly, this also increases the risk of thrombosis, hypertension, and worsening of atherosclerosis. Although not as significant, rofecoxib was also associated with an increased risk of arrhythmia including ventricular fibrillation , cardiac arrest, and sudden cardiac death. Local anesthetics administered via periarticular or intra-articular injections have been shown to decrease pain scores and opioid consumption. The most common agents used in either route of administration were the local anesthetics ropivacaine and bupivacaine.

A combination of intraoperative and postoperative intra-articular ropivacaine-ketorolac injections resulted in lower pain scores, and less opioid consumption and opioid-associated side effects. The corticosteroid component reduces the inflammatory response at the surgical site while reducing blood loss by inhibiting prostaglandin synthesis. The addition of the epinephrine, via its vasoconstrictive mechanism, keeps the analgesic drugs localized to the surgical site longer, maximizing its efficacy and reducing its systemic side effects.

Patients receiving a combination of bupivacaine, triamcinolone, and epinephrine injection before closure had significantly lower pain scores, demanded less parenteral morphine, achieved greater ROM, and had a shorter LOS compared to those who received a similar mixture without the corticosteroid component. When the periarticular injections are compared, the bupivacaine-triamcinolone combination administered postimplantation is more efficacious than ropivacaine alone as well as a ropivacaine-morphine combination administered before closure. Given these findings, it appears that administration of a local anesthetic either intra-articular or periarticular in combination with a steroid or an NSAID before wound closure is more efficacious than the administration of a local anesthetic alone or in combination with an opioid after closure.

This could be explained by a reduction in pain secondary to a decreased inflammatory response, which is seen with steroids and NSAIDs but not with opioid or local anesthetics by themselves. Further studies are needed to assess the effects of time of injection relative to wound closure using the local anesthetic-NSAID and local anesthetic-steroid combination, as well as differences in route of administration intra- versus periarticular , and administration of the NSAID or steroid alone.

Local anesthetic could also be administered through an FNC; however, the benefits may not outweigh the risks when other analgesia protocols are available. However, the benefits associated with this method do not outweigh the risks. For example, this technique is more invasive than previous methods discussed. Not only may more attempts be needed for proper placement of the catheter, operator-dependent errors can also be made that can damage nearby vascular structures. In addition, the decreased ROM associated with this particular protocol can lead to a longer LOS and a longer rehabilitation period. Both of these factors alone will increase the healthcare cost of managing a patient who has undergone ELEA and are detrimental to the overall recovery of the patient.

Among the highest risk pain management modalities is administration of epidural analgesia. Traditional epidural analgesia involving the administration of opioids into the epidural space, although effective, may no longer play a role amidst the multiple more modern and safer techniques available. However, modifications to this traditional method of pain management attempt to reinforce the efficacy of epidural analgesia in the management of postoperative pain. Overall, patients receiving EREM have significantly lower pain scores and less opioid consumption than those receiving spinal anesthesia alone. Interestingly, while patients receiving EREM used less additional narcotics, the action of the long-acting morphine caused these patients to experience significantly more episodes of postoperative nausea and vomiting as well as pruritis.

Additionally, modifying traditional epidural analgesia by shortening the duration of administration has also been beneficial in postoperative pain management. Patients receiving epidural analgesia for only one POD versus two achieved a greater distance walked and had a significantly shorter LOS. It appears that the duration of epidural administration plays a bigger role in its efficacy in postoperative pain management than does the specific opioid being administered. It is important to note that although a shorter duration may allow for more rapid rehabilitation and shorter LOS, the generally invasive nature of placing an epidural may not make this the optimum method of achieving adequate postoperative analgesia, especially in light of the efficacy of other, less invasive modalities.

While distantly related to epidural analgesia, spinal cord stimulation is gradually finding its place amongst other postoperative analgesia protocols. The process involved in placing a permanent spinal cord stimulator can be time consuming, as the precise location and current passed through the device is vital to effectively provide pain control. Summary After having evaluated the efficacy of the various multimodal pain management protocols, the recommended method of pain management following ELEA is a periarticular injection of a mixture containing a corticosteroid, local anesthetic, and epinephrine administered before wound closure.

Relative to the other modalities reviewed, this particular method is the least invasive, yet most effective multimodal analgesia protocol. Although not reviewed in terms of periarticular injections, a possible alternative is the replacement of the corticosteroid component with an NSAID, which was shown to be efficacious when given intra-articularly.

While results of the periarticular injection of steroid and local anesthetic are similar to an intra-articular cocktail of an NSAID and local anesthetic, the significantly shorter LOS makes the former method preferred over the latter. Decreased length of hospital stay is associated with increased patient satisfaction, decreased risk to the patient, and decreased healthcare-associated costs. In conclusion, while the optimum pain management protocol will most certainly vary from case to case, the recommended protocol should provide adequate pain relief to the majority of patients who will be undergoing lower extremity arthroplasty in the near future.

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References Centers for Disease Control and Prevention. Arthritis-related statistics. Updated August 1, Accessed November 16, United States Bone and Joint Decade. Southern California Orthopedic Institute: Total knee replacement. Center for Disease Control and Prevention. Prevalence of doctor-diagnosed arthritis and arthritis-attributable activity limitation—United States, A multimodal clinical pathway can reduce length of stay after total knee arthroplasty. HSS J. Pain management and accelerated rehabilitation for total hip and total knee arthroplasty.

J Arthroplasty. The APS guidelines may not apply to all patients and clinical situations. The official abstract and supplementary data related to this article can be found here. Funding for this guideline was provided by the APS, and all statements related to it are the responsibility of the authors and panel members. All panelists have been required to submit relevant conflict of interest information pertaining to the last 5 years.

Types of Pain Acute Pain. Cancer Pain. Neuropathic Pain. Oral and Maxillofacial Pain. Rheumatologic and Myofascial Pain. Spine Pain. Other Types of Pain. Addiction Medicine. Complementary Treatments. Interventional Pain Management. Manipulation and Massage. Chronic pain sufferers are using our pain specialist directory to find pain specialists in your area. Register now and get your name in front of these patients! Home » Resources » News and Research. February 18, New guidelines published by the American Pain Society provide a comprehensive consensus on essential pain management topics for both adult and children patients and acknowledge significant gaps in clinical knowledge.

Postoperative pain experience: Results from a national survey suggest postoperative pain continues to be undermanaged. Anesth Analg. Incidence, patient satisfaction, and perceptions of postsurgical pain: Results from a US national survey. Curr Med Res Opin. J Pain. A systematic review of randomized trials evaluating regional techniques for post-thoracotomy analgesia. Cryoanalgesia for post-thoracotomy pain relief. Acta Anaesthesiol Belg. Local anesthetic wound infiltration and abdominal nerves block during caesarean section for postoperative pain relief.

Cochrane Database Syst Rev. Does continuous peripheral nerve block provide superior pain control to opioids? A meta-analysis. Modified continuous femoral three-in-one block for postoperative pain after total knee arthroplasty. The posterior lumbar plexus psoas compartment block and the three in- one femoral nerve block provide similar postoperative analgesia after total knee replacement. Can J Anaesth. Combining paracetamol acetaminophen with nonsteroidal anti-inflammatory drugs: A qualitative systematic review of analgesic efficacy for acute postoperative pain. Clin Ther. The efficacy of the non-opioid analgesics parecoxib, paracetamol and metamizol for postoperative pain relief after lumbar microdiscectomy.

Intravenous administration of propacetamol reduces morphine consumption after spinal fusion surgery. Single-dose intravenous paracetamol or propacetamol for prevention or treatment of postoperative pain: A systematic review and meta-analysis. Br J Anaesth. Calcif Tissue Int.

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