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Practical Approach in Postoperative pain management after TKA

Practical Approach in Postoperative pain management after TKA

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Practical Approach in Postoperative pain management after TKA

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  1. Practical Approach in Postoperative pain managementafter TKA BeomKoo Lee Gil Hospital, Gachon university

  2. “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)

  3. 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

  4. 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

  5. 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

  6. 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

  7. Multimodal Targets

  8. 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

  9. The Effect of Preoperative Information on Anxiety of Patient Undergoing Total Knee Arthroplasty Surgery Han Jung Il Gil hospital, Gachon university

  10. 연구결과 3 Repeated measured ANOVA for Cortisol Level EG:Experiment Group CG  Control Group Han Jung Il Gil hospital, gachon university

  11. 연구결과 4 Repeated measured ANOVA for Pain EG:Experiment Group CG  Control Group Han Jung Il Gil hospital, gachon university

  12. Preemptive Analgesia • ↓ Establishment of ppr & central sensitization

  13. Oral Preemptive Analgesia

  14. Preemptive AnalgesicsCurrently Recommended Drugs • Oxycodone (Oxicontin) • Cox-2 inhibitor (Celebrex) • Acetaminophen (Tylenol) • Pregabalin (Lyrica)

  15. 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?

  16. 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

  17. Questionnaire #1: 의사 기록지

  18. Questionnaire #2: 통증 기록지 • Day & Night • 예상통증 • OP #0 • OP #1 • OP #2 • OP #3 • OP #7 • OP #14

  19. Questionnaire #3: QoL 기록지 • EQ-5D • Preop • PO 14D

  20. Questionnaire #4: 만족도 조사 • PO 14D

  21. Results

  22. Use of Pain Mx. Methods (Education) > IV PCA > Epidural ….

  23. Use of Pain Mx in Each Hospital

  24. Average Pain Levels (밤 ≥낮) * * * *

  25. Overall Pain Levels Among Methods rebound Systemic only vs. PMDI + Regional/Epi: p = 0.005

  26. Health Score at PO 2W P < 0.001 Epidural & PMDI + Regional/Epi > Systemic ± Preemptive

  27. 예상보다 통증조절이 잘되었다

  28. 마약성 진통제 부작용으로 고생했다

  29. 수면에 문제가 있다

  30. 전반적으로 치료에 만족하고 있다

  31. 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.

  32. 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.

  33. 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.

  34. Painmanagement after TKA in Gil Hospital

  35. Preemptive Analgesics • 수술장에서 call 오면 투여 • -cerebrex 400mg (2C) 복용시킴 (물 소량과 함께)

  36. 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

  37. post-op • Cerebrex 200mg • Oxycontin 10mg • Lyrica75mg • Acetaminophen 650mg

  38. Thank you for kind attention.