◊ SUMMARY:
In a well-defined fast-track setup for total hip and knee arthroplasty, with a multimodal analgesic regimen consisting of intra-operative local anaesthetic infiltration and oral celecoxib, gabapentin and paracetamol for 6 days postoperatively, we conducted a prospective, consecutive, observational study. The purpose was to describe the prevalence and intensity of subacute postoperative pain and opioid related side effects, use of analgesics and functional ability 1-10 and 30 days postoperatively. Fast-track total hip and knee arthroplasty with early discharge (< 3 days) resulted in acceptable levels of pain and postoperative nausea and vomiting with concomitant low use of opioids in > 95% of patients after discharge before day 10 after total hip arthroplasty. However, after total knee arthroplasty 52% patients reported moderate pain (VAS 30-59 mm), and 16% severe pain (VAS > or = 60 mm) when walking 1 month after surgery with a concomitant increase in the use of strong opioids. These results emphasise the need for improvement in analgesia after discharge following total knee arthroplasty, to facilitate rehabilitation.
◊ Reviewed by P. Grossi,
U.O. Anestesia LocoRegionale e Terapia del Dolore
IRCCS Policlinico San Donato,
S.Donato Milanese, Italy
Boezaart, Ilfeld and many other colleagues demonstrated the efficacy of a new analgesic treatment in early postoperative pain management following lower extremities joint replacement. Local anaesthetic infiltration or peripheral nerve blocks ensure an adequate pain relief in order to improve functional abilities and early rehabilitation and discharge of patients. These improvements call for maintaining adequate pain relief beyond discharge in order to ensure functional abilities of patients at home.
This study describes the prevalence and intensity of subacute pain, the use of analgesic drugs and its impact on functional abilities after total hip or knee arthroplasty in a well-defined fast-track program. As suggested by Fanelli and colleagues, pain treatment has to be tailored to patients’ needs and should address three primary objectives:
- relief from pain on movement (in order to permit an earlier rehabilitation)
- reduction of side effects related to analgesic drugs
- early return to patients’ pre-surgery activity level
For this, it is important to set up a multimodal analgesic treatment which controls for different pain mechanisms and prevents pain from becoming chronic. The therapy, particularly if it is used for several days, has to be safe and side effects related to the analgesic treatment (especially those related to opioids, as nausea and vomiting) need to be avoided.
In this article, Kehlet and his group used a multimodal treatment for 6 days postoperatively comprising NSAIDs (COX2 inhibitors in order to reduce gastric and hemorrhagic side effects), anticonvulsant drugs (to reduce central sensitization and consequent chronicization of pain) and rescue doses of strong opioids, if the pain ran out of control. In the first postoperative period they used local anaesthetic infiltration.
I would like to underline that some authors (for example Ilfeld) prefer peripheral continuous nerve blocks (PCNB) to be continued at home as they may reduce the need for analgesic treatment (and their possible side effects). PCNBs have been demonstrated to reduce peripheral nociceptive inputs (mostly those by A delta fibers responsible for movement pain) to the pain centre resulting in decreased pain on movement, central sensitization, and eventually in the prevention of chronic pain.
Even if the safety of PCNB at home is well established, this kind of analgesic treatment needs a more elaborated ambulatory organization of the Acute Pain Service (more frequent controls and possibility to visit patients if there are problems related to peripheral nerve catheters).
In conclusion, this study emphasizes the need to improve postoperative pain management after discharge from hospital in total hip arthroplasty. Patients may suffer from pain particularly on movement despite using strong opioids for 1 month after surgery. It is demonstrated that the pain during 30 days following total hip arthroplasty is better controlled with less use of analgesic drugs.
The study underlines that it is fundamental to set up postoperative treatments that prevent chronic pain, but also to continuously evaluate patients after discharge, particularly in fast-track programs.
◊ References
1. Boezaart AP.
Perineural infusion of local anesthetics. Anesthesiology 2006; 104:872-80
2. Ilfeld BM et al.
Ambulatory continuous femoral nerve blocks decrease time to discharge readiness after tricompartimental total knee arthroplasty: a randomized triple masked, placebo-controlled study. Anesthesiology 2008;108:703-713
3. Fanelli et al.
Updating postoperative pain management: from multimodal to context-sensitive treatment. Minerva Anestesio 2008;74:489-500
4. Wolf CJ.
Pain:moving from symptom control toward mechanism-specific pharmacologic management. An Intern Med 2004;140:441-51
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