Practical Approach in

Postoperative pain management after TKA  

BeomKoo LeeGil 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 2006 53

Goal of Pain Management

Maximize patient satisfaction (QoL)

Rapid recovery

Rapid return to normal ADL

Better sleep

Increase postop. outcome

Reduce medical cost

Reducing dose of risky pain agents: Opioid

Opioid-Related Side Effect

Sedation

Respiratory distress

Pruritus

Ileus

Urinary Retention

Should be minimizing use of opioid in risk groups Frail elderly (many of TKA pts) Obstructive sleep apnea

(10’ KSSTA, Simult. Bilat TKA)

Multimodal Targets

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 

Variables Group PRE-OP POD 1  P     Mean± SD Mean ±SD

Cortisol EG 12.8 ± 4.7 14.6 ± 5.2

.012  CG 11.2 ± 4.6 20.3 ± 9.0

       

EG: Experiment Group

CG  Control Group Han Jung Il Gil hospital, gachon univer-sity

연구결과 4

 Repeated measured ANOVA for Pain

Variables Group Pre-OP POD 1  P     Mean ±SD Mean ±SD

Pain EG 80.6±14.8 60.6±24.6.012

   CG 70.0±22.0 73.0±19.0

EG: Experiment Group

CG  Control Group Han Jung Il Gil hospital, gachon univer-sity

Preemptive Analgesia

↓ Establishment of ppr & central sensitization

Oral Preemptive Analgesia

OpioidBlocks the pain signal by binding to opioid receptor sites – in the CNS

Opioid S/E

NSAID Blocks the inflow of the pain signal from the site of injury

OP site bleed-ingGI bleeding

Paracetamol(AAP)

Inhibit COX [COX2, (3?)] in Brain Liver toxicity

Anti-convul-sants

(pregabalin and

gabapentin)

Works to decrease the hyper-algesicresponse from the CNS

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 #1: 의사 기록지

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

Results

Use of Pain Mx. Methods

Pain Management Methods No of Patients (%)

Preop. pain education 407 (96.0%)

Preemptive 161 (38.0%)

Epidural 188 (44.3%)

Regional n. block (Femoral n) 74 (17.5%)

Periarticular injection 92 (21.7%)

IV PCA 242 (57.1%)

(Education) > IV PCA > Epidural ….

Use of Pain Mx in Each Hospital

Case Preemptive Epidural Regional PMDI IV PCA

Hosp. 1 30 6 (20%) 16 (53%) 0 (0%) 8 (27%) 14 (47%)

Hosp. 2 30 1 (3%) 　28 (93%) 0 (0%) 0 (0%) 　2 (7%)

Hosp. 3 28 0 (0%) 　27 (96%) 0 (0%) 0 (0%) 　1 (4%)

Hosp. 4 15 7 (47%) 15 (100%) 0 (0%) 0 (0%) 0 (0%)

Hosp. 5 29 16 (55%) 1 (3%) 0 (0%) 2 (7%) 29 (100%)

Hosp. 6 50 50 (100%) 0 (0%) 50 (100%) 50 (100%) 50 (100%)

Hosp. 7 16 0 (0%) 0 (0%) 0 (0%) 0 (0%) 16 (100%)

Hosp. 8 31 0 (0%) 30 (97%) 0 (0%) 0 (0%) 2 (7%)

Hosp. 9 28 23 (82%) 22 (79%) 1 (4%) 0 (0%) 9 (32%)

Hosp. 10 50 0 (0%) 0 (0%) 0 (0%) 0 (0%) 50 (100%)

Hosp. 11 30 27 (90%) 0 (0%) 0 (0%) 8 (27%) 30 (100%)

Hosp. 12 32 0 (0%) 31 (97%) 1 (3%) 0 (0%) 0 (0%)

Hosp. 13 28 27 (96%) 1 (4%) 22 (79%) 24 (86%) 27 (96%)

Hosp. 14 27 4 (15%) 17 (63%) 0 (0%) 0 (0%) 12 (44%)

**

*

*

Average Pain Levels ( 밤 ≥ 낮 )

Overall Pain Levels Among Methods

Systemic only vs. PMDI + Regional/Epi: p = 0.005

rebound

Health Score at PO 2W

Epidural & PMDI + Regional/Epi > Systemic ±

Preemptive

P < 0.001

예상보다 통증조절이 잘되었다

Pain Management Methods Score Range

Systemic analgesic only 2.6 (0.8) 1 - 4

Systemic analgesics + Pre-emptive 2.9 (0.9) 1 - 4

Epidural ± Systemic anal-gesics

2.9 (0.9) 1 - 4

PMDI + Regional n. block or Epidural 2.9 (0.6) 2 - 4

P-value 0.004

마약성 진통제 부작용으로 고생했다

Pain Management Methods Score Range

Systemic analgesic only 2.0 (0.8) 1 - 4

Systemic analgesics + Pre-emptive 1.4 (0.5) 1 - 3

Epidural ± Systemic anal-gesics

1.4 (0.7) 1 - 4

PMDI + Regional n. block or Epidural 1.9 (0.7) 1 - 3

P-value < 0.001

수면에 문제가 있다

Pain Management Methods Score Range

Systemic analgesic only 2.1 (0.8) 1 - 4

Systemic analgesics + Pre-emptive 1.9 (0.7) 1 - 4

Epidural ± Systemic anal-gesics

1.7 (0.7) 1 - 4

PMDI + Regional n. block or Epidural 2.0 (0.6) 1 - 3

P-value < 0.001

전반적으로 치료에 만족하고 있다

Pain Management Methods Score Range

Systemic analgesic only 3.0 (0.8) 1 - 4

Systemic analgesics + Pre-emptive 3.0 (0.9) 1 - 4

Epidural ± Systemic anal-gesics

2.9 (0.8) 1 - 4

PMDI + Regional n. block or Epidural 3.0 (0.7) 2 - 4

P-value 0.650

Summary

There are wide variations in the use of pain man-agement among the high volume knee surgeons in ter-tiary Hosp.

Pain levels of the TKA patients in each hospital also showed wide variations, particularly in early PO pe-riod.

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 out-

standing control of op night pain. However, it had rebound phenomenon.

Adding preemptive analgesics seems to provide bet-ter pain control at op date.

Different pain mx. methods also have significant in-fluence on the level of QoL at 2W TKA. PMDI + regional or epidural block group and

Epidural group show significantly better QoL than other group.

Summary

Pain management after TKA in Gil Hospital

Preemptive Analgesics

수술장에서 call 오면 투여 -cerebrex 400mg (2C) 복용시킴 ( 물 소량과

함께 )

본원 Periarticular drug 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 Lyrica 75mg Acetaminophen 650mg

Thank you for kind attention.