Sunday, January 23, 2011

Multimodal Pain Management During Joint Replacement Surgery

Seth Greenky, MD
Kimberley Murray, RN

We recognize that pain is a major concern for a patient about to undergo hip or knee replacement surgery.  Educating yourself about pain and effective ways to manage it before experiencing surgical pain can reduce your fear and assist you to manage your expectations and ultimately, your post-operative pain. 
Orthopedic surgeons are continuously challenged to find a pain relief regime that reduces the amount of pain that a patient experiences while minimizing the side effects of narcotics and other analgesics.  Inadequate pain control potentially delays physical therapy progress, hospital discharge, and the overall surgical recovery time.  More and more research is emerging that supports the use of a Multimodal Pain Management Strategy as the most effective mechanism to control pain , promote mobility, and improve functional outcomes after hip and knee replacement.
What is it?
Multimodal analgesia or balanced analgesia is the use of more than one method of managing or controlling pain.  It involves administering multiple drug and treatment modalities utilizing more than a single route of administration across the entire surgical course or perioperative continuum including:
·         Preoperative period (before surgery)
·         Intra-operative (during surgery)
·         Post-operative (after surgery)

Post-operative pain is the result of a complex series of events and reactions within the body as the result of the trauma or assault caused by the surgical procedure.  The response to pain is triggered by reactions occurring locally at the site of the surgery as well as centrally in the brain.  Using a combination of methods and drugs to control pain at the surgical site as well as centrally in the nervous system achieves the optimal pain control results.
Preoperative Phase of Care
Measures begin prior to the surgical incision.  They reduce the need for opioid drugs after surgery and usually include a combination of one or more of the following drugs:
·         NSAIDs
o   Nonsteroidal anti-inflammatory drugs that have analgesic, fever-reducing, and inflammation reducing properties
·         Cox-2 Inhibitors
o   A newer type of nonsteroidal anti-inflammatory drug that directly targets an enzyme responsible for inflammation and pain
·         Anti-neuropathics
o   A type of drug that is often used to treat seizures and neuropathic pain syndromes.  Studies have found that these drugs can help reduce the pain signals that are sent to the brain and result in reduced post-operative pain and use of morphine
Intraoperative Phase of Care
Measures are implemented during the surgical procedure.  They may include a combination of one or more of the following:
·         Spinal Analgesia/Spine Block (Regional Anesthesia)
o   Uses local anesthetics to blockade the central sensory and motor receptors for the time during the surgery as well as into the post-operative recovery phase of care
o   Also assists in reducing surgical blood loss and may diminish the incidence of post-operative nausea and vomiting as well
·         Peripheral Nerve Blocks
o   The injection of a local anesthetic onto or near nerves for the temporary control of pain
o   Performed either with a single injection or a continuous infusion through a catheter
·         Intraoperative Injections
o   Use of “cocktails” comprised of morphine, an anti-inflammatory, and a local anesthetic to block the inflammatory and pain pathways
Post-operative Phase of Care
Measures are implemented during the recovery period.  They may include a combination of one or more of the following:
·         Intravenous Patient Controlled Analgesia (PCA)
o   Utilizes infusion pumps to deliver patient initiated  small doses of opioids (morphine, hydromorphone, fentanyl)
o   Patients must be willing and able to actually participate in their care
·         Continuous Non-narcotic, Surgical Site Pain Relief Pump
o   A device that continuously pumps a local anesthetic through a catheter to the surgical site and surrounding area for 1-2 days after the surgery
·         Acetaminophen
o   Results in reduced opioid requirements
There is no single approach to multimodal pain management that has emerged as the best practice method.  There are myriad variations to the approaches used by joint replacement surgeons and anesthesia providers but the elements are similar and they all focus on
·         Getting ahead of pain (preventing it before it begins)
·         Reducing the use of narcotics
·         Reducing nausea and vomiting
·         Diminishing post-operative sleepiness
·         Promotion of early mobility (which also minimizes the risk of deep venous thrombosis—DVT)
·         Contributing to the overall improved surgical outcomes and early discharge from the hospital
If joint replacement surgery is in your near future, be inquisitive and ask your surgeon about his or her adoption of this approach to managing post-operative pain.  Take charge of your health and be your own best patient advocate.

Gandhi, K. & Viscusi, E., Multimodal Pain Management Techniques in Hip and Knee Arthroplasty. The Journal of New York School of Regional Anesthesia, July, 2009.
Harlocker, T., Kopp, S., Pagnano, M.,  & Hebl, J., Analgesia for Total Hip and Knee Arthroplasty:  A Multimodal Pathway Featuring Peripheral Nerve Block.   Journal of the American Academy of Orthopedic Surgeons, March, 2006.
Joshi, GP., Ogunnaike, BO., Consequences of Inadequate Postoperative Pain Relief and Chronic Persistent Postoperative Pain.  Anesthesiology Clinics of North America, 2005.
Poruczni, M., Two Views on Multimodal Pain management. American Academy of Orthopedic Surgeons Now, July, 2010.

1 comment:

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