Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_17_библиотеки_им_акад_М_И_Перельмана
.pdf
Perioperative Pain
https://t.me/medicina_free
Management inTotal Knee
Arthroplasty
MatthewA.Harb, JohnP.Taliaferro, andJamesA.Browne
Contents
25.1 Introduction – 276
25.2 Multimodal Analgesia – 276
25.3 The Pain Pathway – 276
25.4 Preoperative Analgesia – 277
275
25
25.5 Intraoperative Periarticular Injection – 278
25.6 Intraoperative Medications – 279
25.7 Postoperative Analgesia – 280
25.7.1 Gabapentinoids – 280
25.7.2 Nonsteroidal Anti-Inammatory Drugs – 280
25.7.3 Opioids – 281
25.7.4 Intravenous Opioids Via Patient-Controlled Analgesia – 282
References – 283
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer Nature 2022
E. Hansen, K.-D. Kühn (eds.), Essentials of Cemented Knee Arthroplasty,
https://doi.org/10.1007/978-3-662-63113-3_25
276
https://t.me/medicina_free
M. A. Harb et al.
25
25.1 Introduction
Total knee arthroplasty(TKA) is a highly successful procedure for reducing pain and restoring function to
patients with arthritis and debilitating joint disease.
> However, TKA is associated with moderate to severe
pain, and poorly controlled pain in the perioperative
period can hamper both the short- and long-term suc-
cess of the procedure.
Pain management is an important concern for patients
undergoing total knee arthroplasty and the recent shift
to enhanced recovery after surgery and shorter length of
stay has made perioperative pain management increasingly important (Barlow etal. 2015). Inadequate control
of postoperative pain can lead to signicant problems
with rehabilitation and recovery as well as unnecessary
patient discomfort, worse clinical outcomes, restricted
range of motion, arthrobrosis, patient frustration, and
can lead to chronic and neuropathic pain (Dalury etal.
2011; Parvizi etal. 2011; Smith etal. 2017; Harden etal.
2003).
Currently, there are many approaches to perioperative analgesia for patients undergoing TKA. The primary focus of this chapter is on multimodal pain control
and contemporary methods that surgeons can use to
improve patient care and outcomes. Classically, analgesia following total knee arthroplasty was mainly delivered through intravenous and oral opioids. However,
opioids have been associated with multiple undesirable
side effects including over-sedation, constipation, nausea, and dependence.
patient satisfaction, decrease length of stay, and improve
the speed and outcome of the recovery process.
Pain management prior to TKA is increasingly being
recognized as a key component of perioperative pain
management.
> Preoperative opioid use can inuence TKA outcomes;
patients chronically exposed to opioids prior to sur-
gery have been shown to experience more difcult
recoveries and less pain relief from the operation
compared to those who were not prescribed opioids.
The phenomena of opioid-induced hyperalgesia appears
to be a state of nociceptive sensitization caused by exposure to opioids. The condition is characterized by a paradoxical response for which patients receiving opioids
for the treatment of pain become more sensitive to painful stimuli (Smith etal. 2017). Risk for chronic pain has
been noted to be as high as 12.7% in patients 6months
postoperatively with poorly controlled pain (Harden
etal. 2003). Consideration for the limited use of preoperative opioid prescriptions should be made to optimize
surgical outcomes.
25.2 Multimodal Analgesia
Multimodal analgesia includes the following:
5 Preemptive analgesia
5 Oral and intravenous analgesics from two or more
different drug classes
5 Periarticular injection
5 Regional anesthesia
> One of the main goals of multimodal pain control is
to shift the reliance away from opioids and decrease
the undesirable side effects.
Fundamentals of Multimodal Pain Control in TKA
(Parvizi etal. 2011)
5 Spinal analgesia
5 Peripheral nerve blocks
5 Cryotherapy
5 Acetaminophen
5 NSAIDs/COX-2 specic inhibitors
5 Tramadol
5 Local periarticular injections
5 Limited use of opioids
Pain management strategies in TKA include a variety of
these techniques in combination to provide the best possible pain relief, minimize complications, facilitate
The focus is on using a variety of agents to act at different points in the pain pathway. Combining analgesics
can maximize synergistic effects while reducing side
effects (Kehlet and Dahl 1993).
> Multimodal analgesia has been associated with
improved pain control, shorter hospitalization, and
enhanced functional recovery after surgery
(Buvanendran et al. 2003; American Society of
Anesthesiologists Task Force on Acute Pain
Management 2004).
25.3 The Pain Pathway
The current physiological understanding of the pain
pathway suggests that perceived stimulus of pain causes a
recruitment phenomenon in which initial painful stimuli
leads to hyperpolarization of adjacent neural pathways.
This makes subsequent pain more difcult to control.
Inhibited by
substance P
Perioperative Pain Management inTotal Knee Arthroplasty
https://t.me/medicina_free
Inhibited by
NSAIDs and opioids
NSAIDs,
acetaminophen,
and gabapentinoids
277
Inhibited by
NSAIDs and acetaminophen
25
Pain stimulus
Inhibited by
NSAIDs
. Fig. 25.1 The pain pathway. Pain can be inhibited or stimulated
> The target of pain control should thus be preventative
and preemptive.
Dorsal root
ganglion
Stimulated by
prostaglandins,
bradykinin,
If the pain response can be dampened prior to the initial
pain stimulus being experienced, then subsequent pain
control can be achieved more reliably. This is the principle of “preemptive analgesia” (Wang et al. 2002;
Bridenbaugh 1994).
The cause of pain after arthroplasty is related to
mechanical, thermal, and chemical damage. This leads to
the release of mediators at the cellular level such as prostaglandins, bradykinins, and histamine. The release of
these signals leads to pain receptor sensitization, which
lowers the amount of stimulation needed to trigger a pain
response (Carr and Goudas 1999). This neurogenic and
inammatory pathway of pain can be targeted by implementing multimodal pain management techniques to target all aspects of the pain pathway (. Fig.25.1).
25.4 Preoperative Analgesia
Spinothalamic
tract
Thalamus
(brain)
pain sense
5 At our institution, oral acetaminophen 975 mg is
administered 2h before incision if there are no contraindications.
5 COX-2 specic inhibitors such as Celecoxib 200mg
can be given 2h before incision if there are no contraindications such as renal insufciency or prior
gastric ulcers.
5 Oral pregabalin75mg may also be given 2h before
incision but should be avoided in patients over
65years of age and patients with sleeping disorders
such as obstructive sleep apnea. Sedation and respiratory depression can occur when gabapentinoids
are combined with opioids, and gabapentin for preemptive pain control is off-label use of this medication (Cavalcante etal. 2017).
> Pregabalin is preferable to gabapentin as it is more
readily absorbed by the gut at a three-time faster rate
and reaches peak blood concentration levels 1h after
ingestion (Athanasakis etal. 2013).
Preemptive analgesia is dened as medication that has
been administered before the onset of surgical stimuli.
> It has been shown that medications administered
before surgery or trauma can blunt the response of
the peripheral and central nervous system to sensiti-
zation from injury.
These medications can help mitigate early postoperative
pain and decrease the risk of chronic neuropathic pain.
Oral medications that have been given preemptively
include acetaminophen, cyclooxygenase-2 (COX- 2)
inhibitors, and gabapentinoids (Golladay etal. 2017).
Although benzodiazepines had been given preemptively
in the past, this practice is no longer recommended.
Prior perceived benets of anxiolysis and improved
patient satisfaction are outweighed by the adverse effects
of postoperative amnesia, drowsiness, and cognitive
dysfunction (Rogers etal. 2002).
Similarly, we no longer administer opioids preoperatively due to concerns with nausea and confusion.
Preoperative opioids have also been shown to have a signicant association with inferior patient reported outcomes, high complication rate, increasing opioid
consumption after surgery, and an increased risk for
chronic opioid usage (Goplen etal. 2019). Long-acting
278
https://t.me/medicina_free
M. A. Harb et al.
25
opioid usage has also been shown to independently predict perioperative complications in total knee arthroplasty (Sing etal. 2016).
Preoperative Regional Anesthesia
z
> Preoperative regional anesthesia can be used to
decrease the initial peripheral pain signal and also aid
to prevent central pain hypersensitivity.
Peripheral nerve blocks have also been shown to aid in
postoperative pain management. Multiple regional
techniques exist and have been shown to be efcacious.
The adductor canal block is an excellent peripheral
nerve block that is commonly used and is the technique
of choice at our institution. It is generally performed in
the preoperative holding area using ultrasound guidance before the patient is transported to the operating
room. The target of the adductor canal block is the largest sensory contributors from the femoral nerve to the
knee, the saphenous nerve, the branch to the vastus
medialis and the periarticular branches of the obturator
nerve. It has been well documented in the literature that
adductor canal block results in less postoperative analgesia consumption and less pain and rest during activity,
when compared to no regional block (Jiang etal. 2016).
Another block that can be used in isolation or in
combination with the adductor canal block is a block
performed between the interspace between the popliteal
artery and the capsule of the posterior knee (the socalled IPACK block). The goal of this block is to target
the areas that may not be covered by the adductor canal
block. Ultrasound-guided local inltration can be performed by anesthesia in the preoperative holding area.
Studies have shown that visual analog pain scores were
signicantly better in patients that received IPACK
block plus adductor canal block versus adductor canal
block in isolation (Lund et al. 2011). This block has
become a routine part of perioperative pain control at
our institution.
A femoral nerve block was routinely used in the past
and provides excellent pain control. However, we no
longer routinely use this block due to postoperative
quadriceps weakness. This block targets both the motor
and sensory branches of the femoral nerve and prevents
early mobilization due to inability to re the quadriceps
muscles and the risk of falling. It has also been suggested that adductor canal block is superior to femoral
nerve block in terms of pain management (Jiang etal.
2016). If a femoral nerve block is employed, a knee
immobilizer in the early postoperative period should be
used to reduce the risk of falls.
Although not used at our institution, cryoneurolysis
is another potential technique for pain control.
Cryoneurolysis or percutaneous freezing of sensory
nerves targeting the infrapatellar branch of the saphenous nerve and anterior femoral cutaneous nerve is a
newer innovation that has some early literature looking
at efcacy. The goal is to temporarily block sensory conduction without causing permanent damage to the
peripheral nerves. High-quality studies are needed to
look at the use of cryoneurolysis to and determine if it
can be efcacious for perioperative pain control for
TKA without increasing adverse outcomes (Dasa etal.
2016).
25.5 Intraoperative Periarticular Injection
> Perioperative pain management is augmented with
the use of a periarticular injection.
The injection is used to decrease pain at the central and
peripheral levels while minimizing side effects to improve
overall patient outcomes. The goal of these injections is
to safely improve pain control while decreasing narcotic
usage and the associated side effects of opioid medications.
Periarticular injections may include one single local
anesthetic or may involve a mixture of multiple medications. There are a number of different drug “cocktails”
that surgeons have developed and used over the years.
The most common ingredients include morphine, epinephrine, ketorolac, depomedrol, bupivacaine, and lidocaine. Liposomal bupivacaine has also been used for this
purpose. There have been multiple studies trying to
determine the medication (or mix of medications) to
inject, but at this time the data shows no clear superiority of one approach over another. A gold standard has
yet to be established.
> Randomized placebo-controlled trials have shown
that patients who received periarticular injections
used less patient-controlled analgesia at 6, 12, and
24 h postoperatively and had lower postoperative
pain scores in the recovery unit (Busch etal. 2006).
Studies have been conducted in patients undergoing
simultaneous bilateral total knee injection in which
patients reported signicantly lower pain scores in the
knee that received periarticular injection up to 4weeks
after surgery (Mullaji etal. 2010). In an effort to potentiate the analgesic effects, corticosteroids can be added to
the mixture to be injected, although studies have failed
to show improved pain control or Knee Society scores
postoperatively (Christensen et al. 2009).Conversely,
one newer study looking at visual analog pain scores
suggested that adding ketorolac with ropivacaine and
epinephrine to the periarticular injection could improve
scores versus ropivacaine and epinephrine alone (Kelley
Perioperative Pain Management inTotal Knee Arthroplasty
https://t.me/medicina_free
279
25
etal. 2013).One example of a periarticular injection that
has been described in the literature includes ropivacaine
5 mg/mL(49.25 mL), epinephrine 1 mg/mL, (0.5 mL),
ketorolac 30 mg/mL (1 mL), clonidine 100 mg/mL
(0.8mL), and normal saline (48.45mL) for a total volume of 100mL.This mixture has been shown to improve
patient satisfaction and outcomes, and has reduced
recovery times (Kelley etal. 2013; Dalury etal. 2011).
Extended-release liposomal bupivacaine has also
been considered for periarticular injection. One randomized control trial comparing extended release liposomal bupivacaine to standard bupivacaine as part of a
multimodal pain strategy showed no difference in pain
scores but a 100-times increase in the cost with liposomal medication. Extended-release liposomal bupivacaine and standard bupivacaine delivered with an
intra-articular infusion pump compared with placebo
yielded equal decreases in pain scores and opioid consumption in TKA patients (Sankineani et al. 2018).
Other similar studies and a recent meta-analysis have
also concluded that there does not appear to be a clear
clinical benet of liposomal bupivacaine compared to
traditional local anesthetics (Yayac etal. 2019). We no
longer use this medication for periarticular injection.
> A critical step to the efcacy of the periarticular
injection appears to be the technique used to inject
the medication. Technique is critical to providing a
safe and appropriate result.
Injections should be given in a control syringe that
allows for both aspiration and injection. Prior to injection the surgeon should aspirate before injection into
areas of concern. A smaller size gauge spinal needle will
ensure that liquid is relieved with minimal tissue trauma.
The overall goal is to place as much medication into the
soft tissues without seepage into the joint or intravascular injection.
The periosteum of both the femur and tibia is the
primary target of injection due to its innervation.
Flexion of the knee will facilitate protection of the neurovascular bundle. The surgeon must be aware of the
location of the peroneal nerve laterally to prevent any
neuropraxia and postoperative foot drop. Medial and
lateral periosteum of the femur can be injected creating
a wheel to form under the periosteal tissue. The posterior capsule of the knee is heavily innervated and is a
common target for injection although the clinical importance of injecting the posterior capsule is unclear
(Krenzel etal. 2009). The easiest and safest access to the
posterior capsule is prior to implantation of components. One half of the injection should be placed into
the posterior capsule medial, lateral, and central locations.
> Plunging the needle laterally should be avoided to
prevent neurovascular injury or transient postoperative foot drop.
Palpation of the posterior aspect of the femur with the
needle and aspiration allow for safe administration of
the medication. The remaining medication can be
injected into the medial soft tissue sleeve, remaining
periosteum, subcutaneous tissue, fascia, retinaculum,
and both sides of the extensor mechanism, tendon, and
muscle. Careful injection technique can improve the outcomes of periarticular injections for pain control and
have been shown to be well tolerated and safe (Kelley
etal. 2013; Dalury etal. 2011).
25.6 Intraoperative Medications
> Dexamethasone is frequently administered in the
perioperative period to reduce postoperative nausea
and vomiting and may have analgesia effects as well.
Various methods of administration have been reported.
Dexamethasone may be given in the preoperative holding area 1 h before incisions in a dosage amount of
10mg. It has also been described as being given intraoperatively at a dosage of 0.15mg/kg IV or 4–10mg IV at
the start of the surgical procedure. A second dosage of
10mg postoperatively at 6h after surgery can be given.
It has also been described as being given for 1–3weeks
in oral dosage of 5 mg for postoperative pain control
and to decrease inammation.
While there is no consensus protocol for the usage of
dexamethasone at this time, there is literature to support
its usage. A recent study compared patients who were
given no steroids versus a single dosage of 10mg 1h preoperative versus a dosage of 10mg 1 h preoperatively
and a second dosage of 10mg at hours postoperatively.
The study showed a signicantly lower rise in CRP and
IL-6 levels, a decrease in postoperative pain and visual
analog scores, as well as a decrease of postoperative
nauseas and vomiting and total opioid consumption in
patients who received steroids pre- and postoperatively.
It is worth noting that at this time the relative dosage
and optimal route of dexamethasone has yet to be established (Kelley et al. 2013; Wu et al. 2018). There has
been some concern about the associated increased glucose levels with steroid administration, although a
recent study demonstrated that administration of 6 or
12 mg IV dexamethasone before skin incision did not
cause an increase in serum glucose in either diabetic or
non-diabetic patients postoperatively compared with
their baseline postoperative elevation (Godshaw et al.
2019).
280
https://t.me/medicina_free
M. A. Harb et al.
25
Tranexamic acid(TXA) is widely used in total knee
arthroplasty and has been proven to decrease blood loss
and transfusion rate after surgery. One study looking at
visual analog scores and morphine usage at 48h postoperatively of no TXA, intra-articular TXA, and IV
TXA.The study concluded that there was a signicant
decrease in pain scores at 6, 12, and 24h in the intraarticular group compared with the no TXA group and
IV TXA group. There was a signicantly less morphine
usage noted in the intra-articular TXA group. Currently
this topic is controversial and more research is needed to
determine if TXA inuences perioperative pain control
(Fan etal. 2018).
Intravenous acetaminophen has also been used as an
approach to multimodal pain control. It has been shown
that patients receiving IV acetaminophen had a signicant decrease in visual analog scale pain scores between
16 and 24h and a signicant decrease in overall opioid
consumption versus patients not receiving intravenous
acetaminophen (Laoruengthana et al. 2019). When
directly comparing oral versus IV acetaminophen the
literature shows that both groups benet with lower
pain scores, limited opioid usage, and minimal opioid
side effects, but there does not appear to be a clinically
meaningful difference in pain or opioid usage between
the two groups (Westrich etal. 2019; Sun etal. 2018).
25.7 Postoperative Analgesia
> Recently published prospective randomized control
trails have shown that in the perioperative period
after primary total knee arthroplasty, gabapentinoids
do not reduce immediate visual analogue pain scores
although pregabalin has been associated with reduced
postoperative opioid consumption.
Patients taking pregabalin after discharge have been
shown to have lower rates of neuropathic pain and over
all opioid consumption. Patients taking gabapentin did
not show any reduction in pain or opioid consumption.
When looking at low and high dosages of gabapentinoids, it has been shown that there are no differences in
postoperative pain score opioid consumption with differing doses of gabapentinoids, although it is important
to understand that gabapentinoids may increase the risk
of confusion in elderly patients (Buvanendran et al.
2010; Clarke etal. 2009, 2014, 2015; Eloy etal. 2017;
Petersen etal. 2018; Lee etal. 2015; Lunn etal. 2015;
Mathiesen etal. 2008; Paul etal. 2013, 2015; Singla etal.
2014; Yik etal. 2019).
> Respiratory depression is also a concern, particularly
with patients who are also taking an opioid.
At this point, the literature contains limited high- quality
studies looking at gabapentinoids and TKA and it
remains unclear as to whether the risks outweigh any
potential benets.
> Enhanced recovery after surgery protocols advocate
for multimodal opioid-sparing techniques as the basis
for postoperative pain control (Huang etal. 2018).
For this reason the use of neuraxial anesthesia, peripheral nerve block, acetaminophen, and non- steroidal
anti-inammatory drugs are featured prominently. General anesthesia monotherapy with intravenous opioids
are not thought to be conducive to optimal outcomes
after TKA (Lassen etal. 2009).
25.7.1 Gabapentinoids
Gabapentinoids are indicated to treat seizures and neuropathic pain but are often used off-label in the management of surgical pain. Although the exact mechanism of
action of these medications is unknown, gabapentinoids
may act on the calcium channels of neurons to reduce
central sensitization of nociception and inammation.
The use of gabapentinoids has been an expanding area
of interest for multimodal pain management.
25.7.2 Nonsteroidal Anti-Inammatory
Drugs
Nonsteroidal anti-inammatory drugs (NSAIDs)
decrease inammation by non-selectively diminishing
cyclooxygenase production and also have an antinociceptive effect (Maund etal. 2011).
> Systematic reviews have shown that NSAIDs after
major surgery decrease morphine consumption and
reduce postoperative nausea and vomiting.
By targeting COX-1 and COX-2 this leads to a decreased
production of prostaglandins which are involved in the
sensitization of nerve bers to arachidonic acid. COX-1
is located throughout the body while COX-2 enzymes
are focused in areas of inammation. It should also be
noted that blocking the COX-1 pathway can lead to
increased adverse events such as renal impairment,
increased bleeding, and gastrointestinal ulcerations
(Vadivelu etal. 2017).
Perioperative Pain Management inTotal Knee Arthroplasty
https://t.me/medicina_free
281
25
Due to these side effects, the majority of focus for
multimodal pain control protocols is targeted to COX-2
inhibitors. Celecoxib is the medication typically used at
our institution for COX-2 blockade. Etoricoxib and
parecoxib are other options which are of the same drug
class. Prospective studies looking at COX-2 specic
inhibitors have demonstrated superiority of the medication over placebo with regard to postoperative analgesia
in TKA (Zhu etal. 2014; Rawal etal. 2013). It has also
been shown that the optimal administration is preoperative initiation of COX-2 therapy, which leads to better
pain control and improved functional outcomes when
compared with postoperative initiation of therapy alone
(Spreng etal. 2010). Ketorolac has also proven to be an
excellent non-selective COX-1 and COX-2 inhibitor
which has been shown to reduce postoperative pain and
opioid consumption in total knee arthroplasty but
should be avoided in patients with impaired renal function and gastrointestinal bleeding (Schwinghammer
etal. 2017).
25.7.3 Opioids
Traditionally, pain control after TKA was primarily
delivered with oral and intravenous opioid medication
through patient-controlled analgesia or bolus.
> The downside of this approach are signicant side
effects that can range from vomiting, confusion,
lethargy, nausea, depression, urinary retention, ileus,
and pruritis, which are the most commonly reported.
These side effects associated with overreliance on narcotics for pain control can contribute to prolonged hospitalization and increased readmission rates, and
decreased patient satisfaction scores (Lamplot et al.
2014; Oderda 2012). Long-term use of opioids and
addiction are also a major public health concern.
> While opioids still play a large role in multimodal
pain management postoperatively, the focus should
be to reduce opioid consumption as much as reason-
ably possible (Horlocker etal. 2006; Rothwell etal.
2011).
Long-acting oral opioids can maintain stable serum
concentrations by combining rapid onset with prolonged duration of action. In the past there has been
some literature to support the use of long-acting oral
opioids given on a scheduled basis as providing superior
therapeutic concentrations, better bioavailability, and
improved pain control compared with immediate acting
opioids (Golladay etal.
2017). However, it is unlikely
that these benets outweigh the risks of adverse events.
> Caution should be used with the administration of
extended-release opioids in elderly patients because
of a high risk for side effects such as delirium.
It is important to be aware that opioids pose a risk to all
patients when not safely administered. Patients who
receive excess opioids are at signicant risk for adverse
events and our approach is to avoid extended release
opioids to help mitigate this risk.
Tramadol is an opioid thought to have a lower potential for abuse and a lower risk for dependence. Tramadol
does not typically provide the same quantitative pain
relief as stronger opioids but it has been shown to have
a more favorable side effect prole and demonstrated
less systemic side effects (Golladay et al. 2017). This
medication may be a useful option for less severe pain or
for those patients at the highest risk for opioid side
effects or addiction. Two studies comparing tramadol to
non-opioid pain control demonstrated no difference
regards to pain scores but did demonstrate a reduction
in overall opioid consumption (Stiller et al. 2007;
Stubhaug etal. 1995).
> The opioid epidemic is a national crisis and surgeons
are working diligently to improve prescribing habits.
Patients with ongoing chronic pain problems and those
who have taken opioids for prolonged periods are at
greater risk of addiction. To curtail this risk of addiction the CDC recommends limiting prescriptions opioids. It has been shown that the risk of addiction is
125% with patients who take opioids for more than
8days (Lespasio etal. 2019). A prospective cohort study
found that a majority of primary total knee arthroplasty
patients were able to successfully wean off narcotics
2–3weeks after surgery or an average of 16.8days. On
average, 52.8% of patients are off narcotics at 2weeks
and 74.2% of patient no longer required narcotics after
3weeks postoperatively (. Fig.25.2).
One recent study showed that an average of 105 narcotic pills are prescribed to patients following TKA
although the average number of pills actually taken was
52. This left an excess of narcotic pills of over 50 pills per
patient. Based on this data, reducing the quantity of pills
prescribed to patients is advisable and the surgeon should
be wary of patients who continue to request opioids past
4 weeks postoperatively. Management of expectations
and education could promote weaning from narcotics
postoperatively to take the least amount possible to keep
TKA patients mobile (Runner etal. 2020).
25
100
Percentage taking narcotics
days
days
days
days
days
days
days
days
days
days
days
days
https://t.me/medicina_free
282
M. A. Harb et al.
90
80
70
60
50
40
30
20
10
0
0 days
1–3
4–6
7–9
10–12
13–15
16–18
19–21
22–24
25–27
28–30
31–33
34-36
. Fig. 25.2 Postoperative opioid use following TKA.The distribu-
tion of days taking narcotics was right shifted with 52.8% of patients
having stopped narcotics after 2weeks, and 74.2% of patients were
25.7.4 Intravenous Opioids Via
Patient-Controlled Analgesia
The use of patient-controlled analgesia(PCA) pain
pumps were once in widespread use and constituted the
primary method of postoperative pain control following
TKA.
> However, over the past 10 years, this practice has
largely been abandoned.
Oral opioids have been shown to provide equal pain
control compared with IV and have fewer side effects.
Randomized controlled trials comparing PCA with
multimodal pain management not including intravenous opioids found that multimodal group had fewer
adverse effects, less narcotic usage, higher satisfaction
rates, and earlier times to achieve physical therapy milestones. Two recent randomized controlled trials compared oral oxycodone with PCA pumps undergoing
TKA again showed superior pain control with oral medications with less opioid consumption and better functional outcomes. Given the lack of evidence to support
use of the PCA, oral administration of opioids is recommended at this time whenever possible following TKA
(Barletta 2012).
off narcotics by 3weeks postoperatively (Runner etal. (
permission from Elsevier)
Conclusion
z
2020), with
Implementing a comprehensive approach to pain management after total knee arthroplasty is key to a successful outcome. Many approaches exist and the optimal
protocol remains to be dened. Our current approach
based on our institutional protocol to multimodal pain
management around TKA is outlined in the following
overview:
Example of a Multimodal Anesthesia Protocol for TKA
5 Preoperative:
– Celebrex 200mg PO
– Acetaminophen 975mg PO
– Pregabalin 75mg PO (caution in elderly patients,
respiratory depression!)
5 Intraoperative:
– Regional block—adductor canal and IPAC
– Spinal anesthesia (unless contraindication or
patient refusal)
– Periarticular local injection
– Dexamethasone 10 mg IV (caution in diabetic
patients!)
5 Postoperative:
– Acetaminophen 975mg PO TID
– Celebrex 100mg PO BID
Perioperative Pain Management inTotal Knee Arthroplasty
https://t.me/medicina_free
– Pregabalin 75mg PO (to be avoided in patients
age >65, respiratory depression)
– Ketorolac 15 mg IV Q6H prn breakthrough
severe pain (to be avoided in renal dysfunction)
– Dexamethasone 10 mg IV ONCE AM POD1
(caution in diabetic patients!)
– Oxycodone 5–10 mg PO Q4H prn severe pain
(patients age >75: 5mg PO)
This approach continues to be rened as new approaches
and new data become available. Efforts to reduce opioid
consumption, control pain, andenhance recovery
through a multimodal analgesic approach have been
proven to work and should be a part of every TKA
pathway. Multimodal pain management and enhanced
recovery after surgery approaches should be considered
the new standard of care of pain management for TKA.
Take-Home Messages
5 Multimodal pain control is used to improve
pain control, decrease patient complications, shorten length of stay, and improve
functional recovery.
5 Peripheral nerve blocks and periarticular
injections are an important part of multimodal pain control.
5 Surgeons have shifted away from intrave-
nous and extended duration opioid medications post operatively.
5 Multimodal pain management strategies
may include medications such as acetaminophen, NSAIDs, dexamethasone, and pregabalin; the use of these medications should
be weighed against the risk of side effects or
harm in an individual patient.
5 Surgeons have an important role to play in
the opioid crisis through maximizing pain
control using non-opioid medications and
being responsible with prescribing habits.
References
American Society of Anesthesiologists Task Force on Acute Pain
Management (2004) Practice guidelines for acute pain management in the perioperative setting: an updated report by the
American Society of Anesthesiologists Task Force on acute pain
management. Anesthesiology 100:1573
Athanasakis K, Petrakis I, Karampli E, Vitsou E, Lyras L,
Kyriopoulos J (2013) Pregabalin versus gabapentin in the management of peripheral neuropathic pain associated with postherpetic neuralgia and diabetic neuropathy: a cost effectiveness
283
analysis for the Greek healthcare setting. BMC Neurol 13:56.
https://doi.org/10.1186/1471- 2377- 13- 56. PubMed PMID:
23731598; PubMed Central PMCID: PMC3674934
Barletta JF (2012) Clinical and economic burden of opioid use for
postsurgical pain: focus on ventilatory impairment and ileus.
Pharmacotherapy 32(9 Suppl):12S–18S. https://doi.org/10.1002/
j.1875- 9114.2012.01178.x. Review. PubMed PMID: 22956490
Barlow T, Grifn D, Barlow D, Realpe A (2015) Patients’ decision
making in total knee arthroplasty: a systematic review of quali-
tative research. Bone Joint Res 4(10):163–169. https://doi.
org/10.1302/2046- 3758.410.2000420. PubMed PMID: 26450640;
PubMed Central PMCID: PMC4649683
Bridenbaugh PO (1994) Preemptive analgesia—is it clinically rele-
vant? Anesth Analg 78(2):203–204. https://doi.
org/10.1213/00000539- 199402000- 00001. PubMed PMID:
8311268
Busch CA, Shore BJ, Bhandari R etal (2006) Efcacy of periarticu-
lar multimodal drug injection in total knee arthroplasty. A ran-
domized trial. J Bone Joint Surg Am 88:959
Buvanendran A, Kroin JS, Tuman KJ, Lubenow TR, Elmofty D,
Moric M, Rosenberg AG (2003) Effects of perioperative admin-
istration of a selective cyclooxygenase 2 inhibitor on pain man-
agement and recovery of function after knee replacement: a
randomized controlled trial. JAMA 290(18):2411–2418.
doi.org/10.1001/jama.290.18.2411. PubMed PMID: 14612477
Buvanendran A, Kroin JS, Valle CJ, Kari M, Moric M, Tuman KJ
(2010) Perioperative oral pregabalin reduces chronic pain after
total knee arthroplasty: a prospective, randomized, controlled
trial. Anesth Analg 110:199–207. https://doi.org/10.1213/
ane.0b013e3181c4273a
Carr DB, Goudas LC (1999) Acute pain. Lancet 353(9169):2051–
2058. https://doi.org/10.1016/S0140- 6736(99)03313- 9. Review
PubMed PMID: 10376632
Cavalcante AN, Sprung J, Schroeder DR, Weingarten TN (2017)
Multimodal analgesic therapy with gabapentin and its association
with postoperative respiratory depression. Anesth Analg
125(1):141–146. https://doi.org/10.1213/ANE.0000000000001719.
PubMed PMID: 27984223
Christensen CP, Jacobs CA, Jennings HR (2009) Effect of periarticu-
larcorticosteroid injections during total knee arthroplasty. A
double-blind randomized trial. J Bone Joint Surg Am 91:2550
Clarke H, Pereira S, Kennedy D, Andrion J, Mitsakakis N, Gollish J
etal (2009) Adding Gabapentin to a multimodal regimen does
not reduce acute pain, opioid consumption or chronic pain after
total hip arthroplasty. Acta Anaesthesiol Scand 53:1073–1083.
https://doi.org/10.1111/j.1399- 6576.2009.02039.x
Clarke H, Katz J, McCartney C, Stratford P, Kennedy D, Pagé M
etal (2014) Perioperative gabapent inreduces 24 h opioid con-
sumption and improves in-hospital rehabilitation but not
post- discharge outcomes after total knee arthroplasty with
peripheral nerve block. Br J Anaesth 113:855–864. https://doi.
org/10.1093/bja/aeu202
Clarke H, Pagé G, McCartney C, Huang A, Stratford P, Andrion J
etal (2015) Pregabalin reduces postoperative opioid consump-
tion and pain for 1 week after hospital discharge, but does not
affect function at 6 weeks or 3 months after total hip arthro-
plasty. Br J Anaesth 115:903–911. https://doi.org/10.1093/bja/
aev363
Dalury DF, Lieberman JR, MacDonald SJ (2011) Current and inno-
vative pain management techniques in total knee arthroplasty. J
Bone Joint Surg Am 93(20):1938–1943
Dasa V, Lensing G, Parsons M, Harris J, Volaufova J, Bliss R (2016)
Percutaneous freezing of sensory nerves prior to total knee
arthroplasty. Knee 23(3):523–528. https://doi.org/10.1016/j.
knee.2016.01.011. Epub 2016 Feb 10. PubMed PMID: 26875052
Eloy J, Anthony C, Amin S, Caparó M, Reilly MC, Shulman S (2017)
Gabapentin does not appear to improve postoperative pain and
https://
25
284
https://t.me/medicina_free
M. A. Harb et al.
25
sleep patterns in patients who concomitantly receive regional
anesthesia for lower extremity orthopedic surgery: a randomized
control trial. Pain Res Manag 2017:2310382. https://doi.
org/10.1155/2017/2310382
Fan Z, Ma J, Kuang M, Zhang L, Han B, Yang B, Wang Y, Ma X
(2018) The efcacy of dexamethasone reducing postoperative
pain and emesis after total knee arthroplasty: a systematic review
and meta-analysis. Int J Surg 52:149–155. https://doi.
org/10.1016/j.ijsu.2018.02.043. Epub 2018 Feb 23. Review.
PubMed PMID: 29481989
Godshaw BM, Mehl AE, Shaffer JG, Meyer MS, Thomas LC,
Chimento GF (2019) The effects of peri-operative dexamethasone on patients undergoing total hip or knee arthroplasty: is it
safe for diabetics? J Arthroplasty 34(4):645–649. https://doi.
org/10.1016/j.arth.2018.12.014. Epub 2018 Dec 18. PubMed
PMID: 30612830
Golladay GJ, Balch KR, Dalury DF, Satpathy J, Jiranek WA (2017)
Oral multimodal analgesia for total joint arthroplasty. J
Arthroplasty 32(9S):S69–S73. https://doi.org/10.1016/j.
arth.2017.05.002. Epub 2017 May 11. PubMed PMID: 28705543
Goplen CM, Verbeek W, Kang SH etal (2019) Preoperative opioid
use is associated with worse patient outcomes after total joint
arthroplasty: a systematic review and meta-analysis. BMC
Musculoskelet Disord 20(1):234. Published 2019 May 18. https://
doi.org/10.1186/s12891- 019- 2619- 8
Harden RN, Bruehl S, Stanos S, Brander V, Chung OY, Saltz S,
Adams A, Stulberg SD (2003) Prospective examination of painrelated and psychological predictors of CRPS-like phenomena
following total knee arthroplasty: a preliminary study. Pain
106(3):393–400. https://doi.org/10.1016/j.pain.2003.08.009.
PubMed PMID: 14659522
Horlocker TT, Kopp SL, Pagnano MW, Hebl JR (2006) Analgesia for
total hip and knee arthroplasty: a multimodal pathway featuring
peripheral nerve block. J Am Acad Orthop Surg 14(3):126–135.
https://doi.org/10.5435/00124635- 200603000- 00003. PubMed
PMID: 16520363
Huang PS, Gleason SM, Shah JA, Buros AF, Hoffman DA (2018)
Efcacy of intravenous acetaminophen for postoperative
analgesia in primary total knee arthroplasty. J Arthroplasty
33(4):1052–1056. https://doi.org/10.1016/j.arth.2017.10.054.
Epub 2017 Nov 10. PubMed PMID: 29174762
Jiang X etal (2016) Analgesic efcacy of adductor canal block in
total knee arthroplasty: a meta-analysis and systematic review.
Orthop Surg 8(3):294–300. https://doi.org/10.1111/os.12268
Kehlet H, Dahl JB (1993) The value of “multimodal” or “bal-
ancedanalgesia” in postoperative pain treatment. Anesth
Analg 77(5):1048–1056. https://doi.org/10.1213/00000539-
199311000- 00030. Review. PubMed PMID: 8105724
Kelley TC, Adams MJ, Mulliken BD, Dalury DF (2013) Efcacy of
multimodal perioperative analgesia protocol with periarticular
medication injection in total knee arthroplasty: a randomized,
double-blinded study. J Arthroplasty 28(8):1274–1277. https://
doi.org/10.1016/j.arth.2013.03.008. Epub 2013 Apr 20. PubMed
PMID: 23608085
Krenzel BA, Cook C, Martin GN, Vail TP, Attarian DE, Bolognesi
MP (2009) Posterior capsular injections of ropivacaine during
total knee arthroplasty: a randomized, double-blind, placebocontrolled study. J Arthroplasty 24(6 Suppl):138–143
Lamplot JD, Wagner ER, Manning DW (2014) Multimodal pain
management in total knee arthroplasty: a prospective randomized controlled trial. J Arthroplasty 29(2):329–334. https://doi.
org/10.1016/j.arth.2013.06.005. Epub 2013 July 11. PubMed
PMID: 23850410
Laoruengthana A, Rattanaprichavej P, Rasamimongkol S, Galassi
M, Weerakul S, Pongpirul K (2019) Intra-articular tranexamic
acid mitigates blood loss and morphine use after total knee
arthroplasty. A randomized controlled trial. J Arthroplasty
34(5):877–881. https://doi.org/10.1016/j.arth.2019.01.030. Epub
2019 Jan 23. PubMed PMID: 30755381
Lassen K, Soop M, Nygren J etal (2009) Consensus review of opti-
mal perioperative care in colorectal surgery. Enhanced Recovery
After Surgery (ERAS) Group recommendations. JAMA Surg
144:961–969
Lee J, Chung K-S, Choi C (2015) The effect of a single dose of pre-
emptive pregabalin administered with COX-2 inhibitor: a trial in
total knee arthroplasty. J Arthroplasty 30:38–42. https://doi.
org/10.1016/j.arth.2014.04.004
Lespasio MJ, Guarino AJ, Sodhi N, Mont MA (2019) Pain manage-
ment associated with total joint arthroplasty: a primer. Perm J
23:18–169. https://doi.org/10.7812/TPP/18- 169
Lund J, Jenstrup MT, Jaeger P etal (2011) Continuous adductor- canal-
blockade for adjuvant post-operative analgesia after major knee
surgery: preliminary results. Acta Anaesthesiol Scand 55:14–19
Lunn T, Husted H, Laursen M, Hansen L, Kehlet H (2015) Analgesic
and sedative effects of perioperative gabapentin in total knee
arthroplasty. Pain 156:2438–2448. https://doi.org/10.1097/j.
pain.0000000000000309
Mathiesen O, Jacobsen L, Holm H, Randall S, Adamiec- Malmstroem
L, Graungaard B etal (2008) Pregabalin and dexamethasone for
postoperative pain control: a randomized controlled study in hip
arthroplasty. Br J Anaesth 101:535–541. https://doi.org/10.1093/
bja/aen215
Maund E, McDaid C, Rice S, Wright K, Jenkins B, Woolacott N
(2011) Paracetamol and selective and non-selective non-steroidal
anti-inammatory drugs for the reduction in morphine-related
side-effects after major surgery: a systematic review. Br J Anaesth
106(3):292–297. https://doi.org/10.1093/bja/aeq406. Epub 2011
Feb 1. Review. PubMed PMID: 21285082
Mullaji A, Kanna R, Shetty GM etal (2010) Efcacy of periarticular
injection of bupivacaine, fentanyl, and methylprednisolone in
total kneearthroplasty: a prospective, randomized trial. J
Arthroplasty 25:851
Oderda G (2012) Challenges in the management of acute postsurgi-
cal pain. Pharmacotherapy 32(9 Suppl):6S–11S. https://doi.
org/10.1002/j.1875- 9114.2012.01177.x. Review. PubMed PMID:
22956493
Parvizi J, Miller AG, Gandhi K (2011) Multimodal pain manage-
ment after total joint arthroplasty. J Bone Joint Surg Am
93(11):1075–1084. https://doi.org/10.2106/JBJS.J.01095. Review.
PubMed PMID: 21655901
Paul JE, Nantha-Aree M, Buckley N, Cheng J, Thabane L, Tidy A
etal (2013) Gabapentindoes not improve multimodal analgesia
outcomes for total knee arthroplasty: a randomized controlled
trial. Can J Anesth 60:423–431. https://doi.org/10.1007/s12630-
013- 9902- 1
Paul JE, Nantha-Aree M, Buckley N, Shahzad U, Cheng J, Thabane
L etal (2015) Randomized controlled trial of gabapentin as an
adjunct to perioperative analgesia in total hip arthroplasty
patients. Can J Anesth 62:476–484. https://doi.org/10.1007/
s12630- 014- 0310- y
Petersen K, Lunn T, Husted H, Hansen L, Simonsen O, Laursen M
etal (2018) The inuence of pre- and perioperative administra-
tion of gabapentin on pain 3–4 years after total knee arthro-
plasty. Scand J Pain 18:237–245. https://doi.org/10.1515/
sjpain- 2018- 0027
Rawal N, Viscusi E, Peloso PM, Minkowitz HS, Chen L, Shah S,
Mehta A, Chit-kara DK, Curtis SP, Papanicolaou DA (2013)
Evaluation of etoricoxib in patients undergoing total knee
replacement surgery in a double-blind, randomized controlled
trial. BMC Musculoskelet Disord 14:300
Соседние файлы в папке Библиотека им академика М.И. Перельмана