A New Option for Improving Post-op Pain Management
Pain is a complex phenomenon. The International Association for the Study of Pain defines it as “An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”
Orthopaedic surgeons know that the procedures they perform to restore function and mobility also cause pain. Managing that post-operative pain to allow the recovery process to begin can be a challenge.
Recently, an expert panel, led by Roger H. Emerson, MD, addressed this issue in a symposium held in Chicago, Improving Patient Outcomes through Advanced Pain Management Techniques. The symposium was supported by an educational grant from Pacira Pharmaceuticals and produced in conjunction with the International Congress for Joint Reconstruction (ICJR).
Defining the Unmet Need, Providing the Solution: Rapid Recovery in Arthroplasty
John W. Barrington, MD, an orthopaedic surgeon from the Texas Center for Joint Replacement, Plano, Texas, opened the symposium with a discussion of his experience using bupivacaine liposome injectable suspension (EXPAREL; Pacira, Parsippany, New Jersey), a novel long-acting anesthetic that provides pain control for up to 72 hours postoperatively, as part of his multimodal pain relief strategy. He injects EXPAREL, mixed with either epinephrine or Marcaine and epinephrine, into the surgical site of a total knee arthroplasty (TKA) or total hip arthroplasty (THA) for post-operative analgesia.
EXPAREL is an FDA-approved, amide-type local anesthetic that Dr. Barrington said has an established safety profile based on 21 clinical trials (more than 1,300 subjects) and 10 double-blind randomized controlled trials (823 patients). Multiple surgical procedures were investigated in these trials, with EXPAREL doses ranging from 66 mg to 532 mg, depending on the type of surgery.
Dr. Barrington shared the role EXPAREL plays in helping him achieve the 4 Ps of patient satisfaction following hip or knee surgery – pain management, prevent nausea, PT protocols, personal connection. In his experience, EXPAREL provides good pain management, allows for less use of the opioids that can cause nausea, and helps patients ambulate the day of surgery.
Therapeutic Advances in Post-Operative Pain
Girish P. Joshi, MD, a professor of anesthesiology and pain management at the University of Texas Southwestern Medical Center in Dallas, Texas, reviewed the overall goals of pain management:
- Reduce postoperative pain
- Avoid therapy-related complications
- Improve outcomes
- Accelerate post-operative care
- Reduce hospital length of stay
- Improve patient satisfaction
He acknowledged that knowing thegoals is different from achieving them. A number of issues get in the way, he said, including a lack of an evidence-based, procedure-specific approach to pain management, a heavy reliance on opioids, and a tradition of treating in response to pain (in other words, the patient must experience pain before therapy is initiated). Compounding the problem are gaps in analgesia, such as when the patient is transferred from one unit to another (ie, from PACU to a surgical unit) or when the patient is switched from one mode of pain management to another (ie, from intravenous to oral).
Dr. Joshi noted that optimal pain relief is a prerequisite to improved outcomes and mobilization following surgery. He recommends aggressive, procedure- and patient-specific, multimodal analgesia that includes:
- Local/regional analgesia techniques
- Acetaminophen and NSAIDs/COX-2 inhibitors around-the-clock
- Selective use of adjuncts, such as steroids, gabapentin/pregabalin
- Opioids (for rescue only)
EXPAREL Care Pathway Drug Utilization Evaluation in Orthopedic Surgery
Richard J. Hawkins, MD, from the Steadman Hawkins Clinic of the Carolinas, Greenville, South Carolina, shared the results of a study that measured, among other data points, pain scores at rest and during physical therapy, length of stay, and need for assistance with ambulation in 200 patients undergoing TKA. Half the patients received a femoral block for pain management; the other half received multi-modal pain management that included injection of EXPAREL in the surgical site.
By 12 hours post-operatively, the difference in pain control was apparent, with the femoral block patients reporting a higher level of resting pain than the EXPAREL patients (5.5 vs. 4.70, respectively, on a standard 10-point pain rating scale). This difference continued through the 72-hour post-operative time period.
Patients who received the EXPAREL injection were able to ambulate with moderate assistance from one person. Patients in the femoral block group needed assistance from two people to ambulate. The quadriceps muscles are fully functioning in patients who receive EXPAREL versus those who have a femoral block, allowing for faster recovery.
Length of stay, equipment costs, and associated personnel costs were reduced in the EXPAREL group, leading Dr. Hawkins to conclude that EXPAREL is safe and effective in this patient population and that it contributed to reduced costs and increased patient satisfaction.
Pain Management 2013
David F. Dalury, MD, an orthopaedic surgeon with Towson Orthopaedic Associates, Towson, Maryland, noted that achieving adequate post-operative analgesia is a compromise between acceptable pain relief and the side effects of drugs used for pain management. Joint replacement surgery further complicates the situation because the patient needs sufficient pain relief for early ambulation.
In his practice, Dr. Dalury has experimented with various strategies to improve pain management, including spinal anesthesia with patient-controlled analgesia, intrathecal morphine, single-injection peripheral blocks, epidurals, and indwelling catheters peripherally. All options, he felt, were compromises.
He then began using a “cocktail” of drugs that includes pre-operative, intra-operative, and post-operative medications. They key, he said, was pericapsular injections of ropivicaine mixed with epinephrine, toradol, and clonidine.
Patients have done well with this cocktail, but there are still issues that worry Dr. Dalury, including some gaps in analgesia in the post-operative period, side effects such as hypotension, and the complexity of his cocktail. EXPAREL, he says, could be the answer, as it simplifies the pain management approach and is long-acting and safe, according to a growing body of research on its use.
Controlling Pain after TKA: Why Injection Approaches?
Bernard N. Stulberg, MD, from the Cleveland Clinic, in Cleveland, Ohio, has only recently begun using EXPAREL as part of his pain management protocol for knee and hip surgery patients.
Dr. Stulberg noted that patients have been telling their surgeons for years that in addition to long-term success of the procedure, they want to recover quickly, with as little pain and as much function as possible. EXPAREL, he believes, can help because it allows for up to 72 hours of complete pain control, which will make a significant difference in patients’ early recovery and their perception of their surgical intervention.
He said that using a non-opioid like EXPAREL for pain management has a number of advantages, including:
- Improved pain control, which allows for earlier weight bearing and ambulation
- The potential to reduce or eliminate regional blocks, which minimizes the quadriceps muscle weakness that impedes rehabilitation and increases the risk for falls
- The ability to administer it using the infiltration technique surgeons already know and to dilute it with normal saline
- Reduced need for opioids
- No catheter or additional device required
Improving Outcomes of Total Joint Arthroplasty: Using New Tissue Infiltration Techniques
Dr. Emerson, MD, also from the Texas Center for Joint Replacement in Plano, Texas, concluded the symposium by reminding attendees of the deleterious effects of poorly controlled postoperative pain, including increased sympathetic activity, decreased regional blood flow, and platelet adhesion, which can lead to deep vein thrombosis/pulmonary embolism, hypertension, myocardial infarction, and stroke.
As with the other surgeons who presented during the symposium, Dr. Emerson employs multimodal pain management for his TKA and THA patients, which encompasses tissue-sparing surgical techniques, better pain strategies, and appropriate medications.
Dr. Emerson favors reducing the use of opioids and nerve blocks because of their complications, including the increased risk for falls. He believes that infiltrating the surgical site with a longer-acting anesthetic such as EXPAREL represents a new direction in pain control that allows him to reserve opioids for rescue only.