Practical Approach in Postoperative pain managementafter TKA BeomKoo Lee Gil Hospital, Gachon university
“Successful TKA”: Changing Concept • Without Compromising Long-term Goals • Emphasis on Short-term Goals • Shorter Hospital Stay • Quicker Return to Function • Less Pain • Shorter Use of Assistive Devices (Vail, 2004, CORR)
Pain After TKA • TKA: One of the most painful procedure • Very severe in 1W after TKA • Can last for 3M • Affect Outcome • Impede early rehabilitation • ROM, walking ability • Longer hospital stay • Interfere healing process • Poor sleep
Predictors of poor pain outcomes: • age below 60 (17%) compared with above 60 (7%, P< .05). • The first knee was most likely to be in the poor outcome group (13%) compared with the second knee (6%). • In contrast, patients who underwent simultaneous bilateral arthroplasty faired better (2%, P< .01). David W. Elson and Ivan J arthroplasty 200653
Goal of Pain Management • Maximize patient satisfaction (QoL) • Rapid recovery • Rapid return to normal ADL • Bettersleep • Increase postop. outcome • Reduce medical cost • Reducing dose of risky pain agents: Opioid
Opioid-Related Side Effect • Sedation • Respiratory distress • Pruritus • Ileus • Urinary Retention (10’ KSSTA, Simult. Bilat TKA) • Should be minimizing use of opioid in risk groups • Frail elderly (many of TKA pts) • Obstructive sleep apnea
Modalities for TKA • Pre- / Intraoperative • Patient education • Pre-emptive analgesia • Peripheral n. block • Epidural analgesia • Periarticular injection • Postoperative • Continuous IV PCA • Single IV / IM analgesics • Oral / Patch analgesics
The Effect of Preoperative Information on Anxiety of Patient Undergoing Total Knee Arthroplasty Surgery Han Jung Il Gil hospital, Gachon university
연구결과 3 Repeated measured ANOVA for Cortisol Level EG:Experiment Group CG Control Group Han Jung Il Gil hospital, gachon university
연구결과 4 Repeated measured ANOVA for Pain EG:Experiment Group CG Control Group Han Jung Il Gil hospital, gachon university
Preemptive Analgesia • ↓ Establishment of ppr & central sensitization
Preemptive AnalgesicsCurrently Recommended Drugs • Oxycodone (Oxicontin) • Cox-2 inhibitor (Celebrex) • Acetaminophen (Tylenol) • Pregabalin (Lyrica)
Questions • How much variations in use of pain mx. methods among high volume surgeons? • Do such variations have significant influence on peri-op pain levels in TKA patients? • Do such variations have significant influence on peri-op QoL and overall satisfaction?
Study Design • Multicenter study: 16 Hospitals • 2 sessions of consensus meetings • 5 sessions of major investigator meetings • Using self-administered questionnaire • Supervised by trained investigator
Questionnaire #2: 통증 기록지 • Day & Night • 예상통증 • OP #0 • OP #1 • OP #2 • OP #3 • OP #7 • OP #14
Questionnaire #3: QoL 기록지 • EQ-5D • Preop • PO 14D
Questionnaire #4: 만족도 조사 • PO 14D
Use of Pain Mx. Methods (Education) > IV PCA > Epidural ….
Average Pain Levels (밤 ≥낮) * * * *
Overall Pain Levels Among Methods rebound Systemic only vs. PMDI + Regional/Epi: p = 0.005
Health Score at PO 2W P < 0.001 Epidural & PMDI + Regional/Epi > Systemic ± Preemptive
Summary • There are wide variations in the use of pain management among the high volume knee surgeons in tertiary Hosp. • Pain levelsof the TKA patients in each hospital also showed wide variations, particularly in early PO period.
Summary • Different pain mx. methods have significant influence on the level of PO pain within 48 hours after TKA. • PMDI + regional or epidural block showed outstanding control of op night pain. However, it had rebound phenomenon. • Adding preemptive analgesics seems to provide better pain control at op date.
Summary • Different pain mx. methods also have significant influence on the level of QoLat 2W TKA. • PMDI + regional or epidural block group and Epidural group show significantly better QoL than other group.
Preemptive Analgesics • 수술장에서 call 오면 투여 • -cerebrex 400mg (2C) 복용시킴 (물 소량과 함께)
본원Periarticulardrug injection • 1. Ropivacaine 300mg ( 0.75% 20ml *2A) • 2. Morphine sulfate 10mg (5mg *2A) • 3. Ketorolac 30mg (1A) • 4. Cefuroxime 750mg (Alporin 1V) • Add. saline to make 100cc
post-op • Cerebrex 200mg • Oxycontin 10mg • Lyrica75mg • Acetaminophen 650mg