Practical approach in postoperative pain management after tka
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Practical Approach in Postoperative pain management after 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

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Practical Approach in Postoperative pain management after TKA

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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


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

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


Oral Preemptive Analgesia


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

(Education) > IV PCA > Epidural ….


Use of Pain Mx in Each Hospital


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


예상보다 통증조절이 잘되었다


마약성 진통제 부작용으로 고생했다


수면에 문제가 있다


전반적으로 치료에 만족하고 있다


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.


Painmanagement after TKA in Gil Hospital


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


Thank you for kind attention.


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