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

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


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
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 1
Questionnaire #1: 의사 기록지


Questionnaire 2
Questionnaire #2: 통증 기록지

  • Day & Night

    • 예상통증

    • OP #0

    • OP #1

    • OP #2

    • OP #3

    • OP #7

    • OP #14


Questionnaire 3 qol
Questionnaire #3: QoL 기록지

  • EQ-5D

    • Preop

    • PO 14D


Questionnaire 4
Questionnaire #4: 만족도 조사

  • PO 14D



Use of pain mx methods
Use of Pain Mx. Methods

(Education) > IV PCA > Epidural ….



Average pain levels
Average Pain Levels (밤 ≥낮)

*

*

*

*


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.


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.


Pain management after tka in gil hospital

Painmanagement after TKA in Gil Hospital


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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