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    Five Phases of Perioperative Pain Control

    Authors

    Christopher M. Melnic, MD; Nicholas Pulos, MD; and Neil P. Sheth, MD

    Disclosures

    The authors have no disclosures relevant to this article.

    Introduction

    The practice of total joint arthroplasty has experienced numerous changes in the past decade, including:

    • Less-invasive surgical approaches
    • Focused postoperative physical therapy regimens
    • Improved perioperative pain control protocols

    It can be argued that perioperative pain control incorporating a multimodal approach has had the greatest impact on the field, as well as the most reproducible results. [1] The multimodal approach to pain control is based on the concept of administering pre-emptive analgesia to prevent pain pathways from becoming “revved up” and causing significant postoperative pain. This is important: Historically, postoperative pain had been treated with increasing doses of intravenous narcotics that resulted in serious side effects but did not provide meaningful reduction in pain. The new approach to treating perioperative pain allows patients to have a less painful experience following total joint arthroplasty.

    Perioperative pain control surrounding total joint arthroplasty occurs in five interrelated phases:

    • Initial office visit
    • Pre-hospital
    • Morning of surgery
    • Intraoperative
    • Postoperative

    Each phase has specific goals that focus on setting patient expectations and administering medications to allow for pre-emptive analgesia.

    Phase 1: The Initial Patient Visit

    Pain control begins at the initial preoperative visit in which the patient completes paperwork for a primary total joint replacement. The orthopaedic surgeon starts the process of setting expectations by asking about the patient’s level of social support. A patient who has adequate social support (for example, who lives at home with family/spouse and currently works) should be given the expectation of being discharged to home following total joint replacement. Setting this expectation early tells the patient that postoperative pain control will be adequate to allow for functioning in the home.

    The surgeon should also discuss the expected process for perioperative pain control: use of regional anesthesia, use of oral pain medications in conjunction with other oral pain medications, and avoidance of intravenous narcotics. Reviewing this protocol in detail will help to decrease the patient’s anxiety regarding postoperative pain. 

    In addition, the patient should receive a test dose of a long-acting narcotic, such as 10 mg of oxycodone (OxyContin) to gauge how he or she reacts to a long-acting narcotic when not under the stress of surgery. Ask the patient to take the test dose at home 2 weeks before surgery. (Make sure he or she knows to take the dose after eating, with another person present, and on a day when he or she is not planning on driving.)

    The patient should call the office the next day to report on the experience with the medication – adequate, too strong, or not strong enough. This feedback will allow the surgeon to individual the patient’s pain protocol and determine the medication dose that should be given to the patient postoperatively while in the hospital and for 10 days following the procedure. 

    The surgeon should also discuss with the patient the role of pre-habilitation [2] and pre-operative conditioning in optimizing the patient’s preparation for surgery. In addition, answering all patient and family questions should be a priority during the initial visit, as anxiety associated with a surgical procedure can result in an excessive postoperative pain response. [3]

    Phase 2: Pre-hospital

    In the weeks leading up to surgery, all newly started narcotics should be stopped. If applicable, the patient should be counseled to wean off of as much narcotic pain medication as possible to have a better chance to control postoperative pain. 

    The night before surgery, the patient is called to review the specifics of the surgery, such as type of procedure, side of surgery, prophylaxis for deep vein thrombosis, discharge destination (home versus rehabilitation facility), and expected length of stay in the hospital). A study from the anesthesia literature [3] indicates that preoperative anxiety relates to postoperative pain. Anecdotally, patients typically tell the holding area staff that they are less anxious due to the phone call from the surgeon the night before.

    The patient is given a prescription for a 5% lidocaine patch (Lidoderm) at the time of the initial office visit. The patient is counseled to place this patch over his or her lower back after showering on the morning of surgery. This will anesthetize the peri-spinal tissue by the time the patient arrives at the hospital and ensure more complete pain relief when undergoing a spinal injection prior to the procedure.

    Phase 3: The Morning of Surgery, at the Hospital

    Following arrival at the hospital, the patient should receive series of medications as part of a preoperative pain management protocol. Although different hospitals may have slightly different protocols, they have in common a basic principle: the use of multiple drugs in concert has a synergistic effect with regard to pre-emptive analgesia. In general, long-acting narcotics are given in conjunction with drugs that counter nausea, pyrexia, neuropathic pain, inflammation, and gastrointestinal reflux.

    In addition to receiving a preoperative cocktail of pain medications, the patient will typically undergo some type of regional anesthesia. The exact protocol used at the authors’ institution has been previously outlined by Pulos and Sheth. [4]

    Phase 4: Intraoperative

    At the time of the procedure, an intraoperative cocktail of analgesics and anesthetics should be injected into the hip or knee capsule, as well as into the surrounding soft tissues. Prior to performing the planned arthrotomy, local anesthetics used should be injected to maximize the benefit of pre-emotive analgesia. [5]

    Phase 5:  Postoperative

    The key element of the postoperative phase of pain control is minimization of the use of intravenous narcotics. Instead, the patient should receive a long-acting oral narcotic (dosing based off of the preoperative test dose) in conjunction with an anti-neuropathic pain agent and an anti-inflammatory. Other drugs that counter nausea, pyrexia, and reflux are typically used while the patient is an inpatient.

    Several adjuncts can be used to minimize postoperative pain. Utilizing subcutaneous sutures instead of staples for wound closure results in better cosmesis for the patient, as well as less anxiety regarding suture removal.  Avoiding routine use of an indwelling urinary catheter will decrease postoperative discomfort related to the catheter and its removal and allow the patient to void on postoperative day one. Some type of occlusive dressing should be used to protect the wound and allow the patient to shower immediately on discharge to home.

    Routine use of a continuous passive motion machine should be avoided, as it may lead to increased swelling and bleeding within the knee joint, exacerbating postoperative pain. [6] 

    Following discharge from the hospital, long-acting and short-acting oral narcotics are typically used for 10 days and 6 weeks, respectively. An anti-inflammatory medication and a neuropathic pain agent are used for 6 weeks. 

    As pain from inflammation decreases with concomitant improvement in function, the patient is often able to stop narcotics and resume normal activities of daily living.

    Conclusion

    Anything that can be done during these five phases to minimize pain and provide pre-emptive analgesia should result in quicker recovery and improved patient satisfaction following total joint replacement.

    Author Information

    Christopher M. Melnic, MD, and Nicholas Pulos, MD, are residents in the Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania. Neil P. Sheth, MD, is an Assistant Professor, Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.

    References

    1. Wulker N, Lambermont JP, Sacchetti L, Lazaro JG, Nardi J. A Prospective Randomized Study of Minimally Invasive Total Knee Arthroplasty Compared with Conventional Surgery. J Bone Joing Surg 2010: 92(7): 1584-1590.
    2. Rosenberg AG. A two-incision approach: promises and pitfalls. Orthopedics 2005;28(9): 935-6.
    3. Thomas T, Robinson C, Champion D, McKell M, Pell M. Prediction and assessment of the severity of post-operative pain and of satisfaction with management. Pain 1998;75(2-3): 17-85.
    4. Pulos N, Sheth NP. Perioperative Pain Management Following Total Joint Arthroplasty. Ann Orthop Rheumatol 2014;2(3): 1029.
    5. Hebl JR, Dilger JA, Byer DE, Kopp SL, Stevens SR, Pagnano MW, Hanssen AD, Horlocker TT. A pre-emptive multimodal pathway featuring peripheral nerve block improves perioperative outcomes after major orthopedic surgery. Reg Anesth Pain Med 2008;33(6): 510-7.
    6. Pope RO, Corcoran S, McCaul K, Howie DW. Continuous passive motion after primary total knee arthroplasty. Does it offer any benefits? J Bone Joint Surg BR. 1997;79(6): 914-7.