The document discusses key concepts in pain management following hip and knee arthroplasty. It defines pain and discusses what patients want after surgery like mobility and pain management. It outlines the benefits of a multimodal approach using techniques like neuraxial blocks, peripheral nerve blocks, and local infiltration to provide good pain relief with fewer side effects than opioids alone. This multimodal, balanced approach can lead to early mobilization, recovery and discharge from the hospital.
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Pain management after joint replacement surgery
1. Key Concepts In Pain
Management Following Hip
& Knee Arthroplasty
Dr Pranav Bansal
Associate Professor
Dept of Anaesthesiology &
Critical Care
BPS Govt. Medical College for Women, Khanpur Kalan,
Sonepat
2. An unpleasant sensory and emotional experience
associated with actual or potential tissue damage or
described in terms of such damage.
IASP Pain Definition (1994, 2008)
According to Katz and Melzack, pain is a personal
and subjective experience that can only be felt by
the sufferer.
It is easier to find men who will volunteer to die, than
to find those who are willing to endure pain with
patience. Julius Caesar
What is Pain?
3. Patients' overall ranking (median scores) of the importance of
addressing questions regarding joint replacement surgery:
Macario et al 2008
n= 29 19
Hip Knee
Will the surgery affect my abilities to care for myself? 5 5
Am I going to need physical therapy? 5 5
How mobile will I be after my surgery? 5 5
When will I be able to walk normally again? 5 5
What are my options if I decide not to receive surgery? 5 4
Will the surgery cause pain afterwards? 5 4
How long will I be in the hospital? 5 4
Is there anything I can do to eliminate
pain after surgery? 4 5
Will I receive medication to manage the pain? 4 4
What do Arthroplasty patients want?
4. What do surgeons want?
Complete pain free post –operative period but along
with:
Early mobilization
Enhanced recovery
Maintained muscle power
Minimal complications
5. What do Anaesthetists want?
Good quality analgesia for patients
Incorporate newer Regional Anaesthesia
techniques: e.g. Neuraxial blocks with newer
additivies and USG guided Nerve blocks to improve
outcomes
Maintain clinical skills
Optimise patient outcome
6. Consequences of poorly managed
acute post-operative pain
The Patient may suffer from:
CVS: Tachycardias, Ischaemia
Hypercoagulable state: DVT
Diminished range of joint motion and
Arthrofibrosis are closely related to
the degree of postoperative pain
7. Psychological: Anxiety, Depression, Sleep
Deprivation
Prolonged hospital stays, increased hospital
readmissions and increased opioid use
ForThe Healthcare professional:
Low Morale
Complaints to/towards/against Institute
Litigation
Consequences of poorly managed
acute post-operative pain
9. Current Problems
Small studies- poor power, less than ideal
design
Too Many studies, Older studies, Contradictory
outcomes
Most studies at single centre i.e. Not the ‘real world’
Rubbish statistics e.g. ‘Average pain score was 2.2 (1-
5)
Studies looking at only 1 thing e.g. Pain and fail to
incorporate the concept of ‘Early Mobilisation or Rapid
recovery’
13. The administration of analgesic agents prior to an
injury in order to prevent development of central
nervous system hyperexcitability or
Preemptive analgesia
14. Non-Opioid drugs :
Antineuropathic : Pregablin 150 mg or Gabapentin
1200 mg PO
COX 2 inhibitors: Celecoxib 400mg or Valdecoxib 40
mg PO
NSAIDS: Ketorolac 15-30mg PO/IV; Ibuprofen 400-
800 mg
-Reduce excess intra-operative opioid usage
-Reduce the possible effect of opioid-induced
hyperalgesia (paradoxical lowering of pain
threshold resulting in greater opioid requirements)
post-operatively
Preemptive analgesia
15. Using rofecoxib 24 hours and 1 hour before
surgery with continued postoperative drug
administration for 14 days had better
outcomes in total knee arthroplasty. These
patients showed reduced opioid
requirements, faster time to physical
rehabilitation, reduced nausea and
vomiting, better sleep patterns and
greater patient satisfaction after surgery.
Buvanendran A, Kroin JS, Tuman KJ, Lubenow TR,
Elmofty D, Moric M, Rosenberg AG. Effects of
Perioperative Administration of a Selective
Preemptive analgesia
16. Spinal anesthesia is administered using 10-15mg
bupivacaine.
Addition of Fentanyl 20-25 ug increases the post
operative analgesia for 2-3 hours.
Addition of Clonidine 25-50 ug increases the post
operative analgesia for 6-8 hours.
Addition of Morphine 0.2-0.3 mg extends the post
operative analgesia for 12-15 hours.
Intrathecal Analgesics
17. Epidural Anaesthesia/Analgesia
Epidural Catheter placed in lumbar segments.
LA+ Opioids given via bolus dosing, Infusion pump or
Patient Controlled Analgesia pump
•Superior analgesia
compared to
Intravenous drugs
•Reduced systemic
opiate requirements
•Can extend analgesia
for postoperative
period
18. Provides better analgesia than IV drugs at rest and
during mobilization.
Can be connected to PCA pump for continuous
analgesia.
Side effects:
Motor blockade may increase probability of patient fall
during mobilization.
In patients on anti-coagulants insertion and removal
of catheter required extra precautions
Arterial hypotension
Retention of urine
Epidural Analgesia
21. Advantages of PCA:
Allows patient participation and gives them
autonomy in their treatment
Rapid titration
Precise Analgesic calculations for scientific
studies
Reduced analgesic requirements
Reduced incidence of breakthrough pain
Less staffing and monitoring concerns
22. Drugs for Post-operative analgesia
Acetaminophen (Paracetamol)
Excellent drug for Mild to Moderate pain
Typical dose: 1gm IV every 6-8Hrs (upto 4 g / 24 hrs)
NSAIDs (Diclofenac Sodium, Ketorolac)
No physical dependence
Ceiling effect
Warnings: ↓dose / avoid if: GI ulceration, Renal dysfunction,
Bleeding disorders / Coagulopathy
Tramadol (50-100 mg IV every 6-8 hr)
Mild to Moderate Post-op pain
Side effect: Nausea and Vomiting
23. Opioids
Codiene, Morphine, pethidine, fentanyl,
methadone, sufentanyl, oxycodone
Side Effects include: Nausea / Vomiting,
Pruritus, Sedation, Constipation, Urinary
Retention, Ileus, Respiratory Depression
Lidocaine (Lox) – fast onset, short duration of
action
Bupivacaine (Sensorcaine) – slow onset, longer
duration
Ropivacaine: longer duration, less cardiotoxic
Local Anaesthetics
25. Femoral Nerve Block superior to Patient
Controlled Analgesia (PCA) in TKA
Femoral block can provide analgesia upto 12-14 hrs
following TKA.
Femoral block compared to PCA via Epidural route:
Hunt 2009 better analgesia
Wang 2002 better analgesia
Ng 2001 better analgesia
Allen 1998 better analgesia
26. Role of Sciatic Nerve Block in Total knee
Replacement
Sciatic nerve provides innervation to posterior part
of knee joint
Fowler et al. BJA 2008; Systematic review
8 studies included; n=464 knee replacement
Most common PNB :femoral sheath catheter (5),
single shot femoral (2), continuous lumbar plexus
block (1).
Femoral nerve block
Comparable analgesia to epidural but less
hypotension
27. Psoas compartment block: Hip/Knee
Psoas compartment: Femoral/Obturator/lateral
cutaneous nerve thigh
Touray et al. BJA 2008: Syst review 30 studies- 20 RCTs
Mildly superior to IV opiates and ‘3-in-1’ block <8 hours
Technically Difficult
As good as epidural if catheter used
Single injection reduces pain for 4-8hrs
Other analgesics required in 18% TKA
Catheter can extend analgesia beyond 8hrs
Complications: Epidural extension
28. Epidural Vs Continuous femoral nerve block Vs PCA
and effect on rehabilitation after Hip arthroplasy
Singelyn et al. 2005
45 patients; Hip arthroplasy under GA
3 groups: Epidural / continuous femoral nerve block
(FNB)/ PCA
All patients had:
similar pain relief,
comparable rehabilitation
duration of hospital stay
Patients with Continuous FNB had less side effects
(nausea/vomiting, urinary retention, hypotension,
catheter problems)
Limitation: Small group size
29. Local Infiltration Therapy
Review Done by Denis Mc Carthy (2013) on 10
RCT’s on Local Infiltration Analgesia following
THA showed reduced post operative opioid
requirements and more patient satisfaction.
Review by S. Brener (2012) on 13 RCT’s concluded
that the impact on pain and length of stay in
hospital in patients undergoing either total hip or
knee arthroplasty were inconsistent.
Limitation: Different cocktails in varying
concentrations and volumes
30. Ranawat Orthopaedic Center (ROC) cocktail for
local infiltration in joint with/without catheter
Medication Strength/dose Amount
First injection
Bupivacaine 0.5% (200–400
mg)
24 cc
Morphine sulphate 8 mg 0.8 cc
Epinephrine (1:1000) 300ug 0.3 cc
Methylprednisolone 40 mg 1 cc
Cefuroxime 750 mg 10 cc (reconstituted in
NS)
Sodium chloride 0.9% 22 cc
Second injection
Bupivacaine 0.5% 20 cc
Sodium chloride 0.9% 20 cc
Clonidine transdermal patch applied in operating room (100ug/24
hours). No steroid in diabetics, immunocompromised, elderly (80
years) or revisions. Vancomycin used if patient allergic to
31. Multimodal (Balanced) Analgesia
Using more than one drug for pain control
Different drugs with different mechanisms/
sites of action along pain pathway
Each with a lower dose than if used alone
Additive/ synergistic effects on Analgesia
Lesser side effects (mainly opiate related S/E)
32. Multimodal analgesia regimes after
Arthroplasty at PPMC, Pennsylvania, Philadelphia
Preoperative: Gabapentin 300mg PO + Celecoxib 200mg
PO + Acetaminophen 1g PO (2hrs before procedure)
Intraoperative: Spinal anesthesia using 10-15mg
bupivacaine
Postoperative: Continuous Femoral nerve or adductor
canal block infusion – 0.2% Ropivacaine @ 8-10mls/hr in
case of Knee arthroplasty.
Single shot Lumbar plexus or Fascia Iliaca block in case of
Hip Joint arthroplasty.
Gabapentin 300mg PO Q8 for 7 Days .
Celecoxib 200mg PO for 72 hrs.
Acetaminophen 1g PO for 72 hrs.
Oxyodone PO
33. Spinal single shot (Add Opioids e.g.
Morphine)
Epidural catheter Yes
Lumbar plexus/Psoas compartment block ??
Local joint infiltration Yes
Femoral Nere block Yes
Sciatic Nerve Block No
Systemic NSAID’s / Paracetamol Yes
Systemic: Opioids Yes (titrated)
(In cases of breakthrough pain)
Analgesia after Arthroplasty
(In a Nutshell)...
34. .......In a Nutshell
Prefer Multi-modal approach for an excellent
Post Operative analgesia thus leading to:
Improved patient satisfaction and Doctor-Patient
relationship.
Early Mobilisation
Early Discharge
Reduced Complications
↓ likelihood of chronic pain