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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

Practical Approach in Postoperative pain managementafter TKA

BeomKoo Lee

Gil Hospital, Gachon university

successful tka changing concept
“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
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
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
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
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
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
slide11

The Effect of Preoperative Information on Anxiety of Patient Undergoing Total Knee Arthroplasty Surgery

Han Jung Il

Gil hospital, Gachon university

slide13
연구결과 3

Repeated measured ANOVA for Cortisol Level

EG:Experiment Group

CG  Control Group

Han Jung Il

Gil hospital, gachon university

slide14
연구결과 4

Repeated measured ANOVA for Pain

EG:Experiment Group

CG  Control Group

Han Jung Il

Gil hospital, gachon university

preemptive analgesia
Preemptive Analgesia
  • ↓ Establishment of ppr & central sensitization
preemptive analgesics currently recommended drugs
Preemptive AnalgesicsCurrently Recommended Drugs
  • Oxycodone (Oxicontin)
  • Cox-2 inhibitor (Celebrex)
  • Acetaminophen (Tylenol)
  • Pregabalin (Lyrica)
questions
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
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
Questionnaire #2: 통증 기록지
  • Day & Night
    • 예상통증
    • OP #0
    • OP #1
    • OP #2
    • OP #3
    • OP #7
    • OP #14
use of pain mx methods
Use of Pain Mx. Methods

(Education) > IV PCA > Epidural ….

overall pain levels among methods
Overall Pain Levels Among Methods

rebound

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

health score at po 2w
Health Score at PO 2W

P < 0.001

Epidural & PMDI + Regional/Epi > Systemic ± Preemptive

summary
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.
summary1
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.
slide36

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
Preemptive Analgesics
  • 수술장에서 call 오면 투여
  • -cerebrex 400mg (2C) 복용시킴 (물 소량과 함께)
periarticular drug injection
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
post-op
  • Cerebrex 200mg
  • Oxycontin 10mg
  • Lyrica75mg
  • Acetaminophen 650mg
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