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Predictors for moderate to severe acute postoperative pain after total hip and knee replacement

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Abstract

Purpose

The ability to identify and focus care to patients at higher risk of moderate to severe postoperative pain should improve analgesia and patient satisfaction, and may affect reimbursement. We undertook this multi-centre cross-sectional study to identify preoperative risk factors for moderate to severe pain after total hip (THR) and knee (TKR) replacement.

Methods

A total of 897 patients were identified from electronic medical records. Preoperative information and anaesthetic technique was gained by retrospective chart review. The primary outcomes were moderate to severe pain (pain score ≥ 4/10) at rest and with activity on postoperative day one. Logistic regression was performed to identify predictors for moderate to severe pain.

Results

Moderate to severe pain was reported by 20 % at rest and 33 % with activity. Predictors for pain at rest were female gender (OR 1.10 with 95 % CI 1.01–1.20), younger age (0.96, 0.94–0.99), increased BMI (1.02, 1.01–1.03), TKR vs. THR (3.21, 2.73–3.78), increased severity of preoperative pain at the surgical site (1.15, 1.03–1.30), preoperative use of opioids (1.63, 1.32–2.01), and general anaesthesia (8.51, 2.13–33.98). Predictors for pain with activity were TKR vs. THR (1.42, 1.28–1.57), increased severity of preoperative pain at the surgical site (1.11, 1.04–1.19), general anaesthesia (9.02, 3.68–22.07), preoperative use of anti-convulsants (1.78, 1.32–2.40) and anti-depressants (1.50, 1.08–2.80), and prior surgery at the surgical site (1.28, 1.05–1.57).

Conclusions

Our findings provide clinical guidance for preoperative stratification of patients for more intensive management potentially including education, nursing staffing, and referral to specialised pain management.

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Acknowledgment

Funding was provided by the Department of Anesthesiology, Hospital for Special Surgery. Dr. Ma was partially supported by Clinical Translational Science Center (NIH UL1-RR024996). Dr. Della Valle is a consultant for Biomet, Convatec and Smith & Nephew and receives research support from Smith & Nephew and Zimmer. Dr. Sculco receives research support from Exactech.

Conflict of interest

The authors declare that they have no conflict of interest.

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Correspondence to Spencer S. Liu.

Appendix

Appendix

At HSS, patients typically received patient controlled epidural analgesia (PCEA) with 0.06 % bupivacaine with hydromorphone 10 mcg/ml or clonidine 1 mcg/ml after central neuraxial anaesthesia. Initial settings were continuous infusion of 4 ml/h, bolus dose 4 ml, lockout time ten minutes, and one hour lockout of 20 ml. TKR patients also receive a single shot femoral nerve block with 30 ml 0.25 % bupivacaine. Patients were assessed twice a day by our Acute Pain Service (APS) consisting of an anaesthetist attending and a pain specialist registered nurse. Patients were typically started on oral analgesics on the night of surgery, and the continuous infusion was decreased as tolerated until successful conversion to oral analgesics only. For example, most patients having unilateral total knee replacement had their continuous infusion decreased to 2 ml/h on the morning of postoperative day (POD) one and then decreased to 0 ml/h on the evening of POD1 followed by discontinuing the PCEA on the morning of POD2. Meloxicam (7.5–15 mg q day) was administered as a standard adjunct analgesic unless contraindicated by active cardiovascular disease, liver disease, renal disease, or sensitivity to NSAIDs. Analgesic adjuncts such as pregabalin were prescribed at the discretion of the APS. There were standing orders for nalbuphine 5 mg iv as an anti-pruritic and ondansetron 4 mg iv as an anti-emetic. Patients undergoing THR and TKR are enrolled in multi-disciplinary clinical pathways that initiate physical therapy either on the afternoon of surgery or morning of POD1. Both pathways target BID ambulation on POD1 followed by progressively more activity. The TKR pathway includes continuous passive motion devices BID. For pharmacological deep venous thrombosis (DVT) prophylaxis, a nomogram [23] is used to dose coumadin to achieve an INR of 1.8–2.5 on postsurgical day 4.

At Rush University Medical centre, patients typically received PCEA with 0.1 % bupivacaine with fentanyl 5 mcg/ml after spinal anaesthesia. Initial settings were continuous infusion of 6 ml/h, bolus dose 1 ml, lockout time 15 min, and one hour lockout of 10 ml. Patients were assessed twice a day. Patients were typically started on oral analgesics on the night of surgery, and the continuous infusion was decreased as tolerated until successful conversion to oral analgesics only. On POD2, the epidural was discontinued and patients commenced on oxycodone extended release 10 mg BID. Preoperative and postsurgical celecoxib (200 mg day) was administered as a standard adjunct analgesic unless contraindicated by active cardiovascular disease, liver disease, renal disease, or sensitivity to NSAIDs. Analgesic adjuncts such as pregabalin were prescribed at the discretion of the APS. For pharmacological deep venous thrombosis (DVT) prophylaxis, a nomogram [23] is used to dose coumadin to achieve an INR of 1.8–2.5 on POD4.

At MGH, patients undergoing TKR typically receive spinal anaesthesia using 3 ml of bupivacaine 0.5 % and THR patients receive general anaesthesia. A portion of patients are placed on IV PCA hydromorphone 0.2 mg q10 min with no basal rate (1 h max = 1.5 mg) titrated to adequate pain control over the first 24 h. These patients are then usually converted to oral analgesics on POD1 with oxycodone 5 mg/acetaminophen 325 mg 1–2 tabs q4h PRN. The rest of the patients are started on oral analgesics immediately in the postoperative period with additional oxycodone extended release 10 mg BID. Most patients in addition were prescribed NSAID’s either as ketorolac or ibuprofen 400–600 mg q8h PRN. After THR, 68 % of patients received acetaminophen 650 mg q6h PRN pain postoperatively. Physical therapy for both TKR and THR patients is typically started on POD1 with at least BID ambulation and followed by progressively increased activity. If the patient receives PCEA, passive range of motion is performed BID in TKR patients until the epidural catheter is discontinued. For pharmacological DVT prophylaxis, patients are usually started on scheduled subcutaneous heparin or subcutaneous dalteparin.

At Sunnybrook, patients typically received acetaminophen 1,000 mg, celecoxib 400 mg, and gabapentin 600 mg approximately two hours prior to surgery. TKR patients receive either a femoral nerve block or a catheter accompanied with a sciatic nerve block prior to surgery. Central neuraxial (90 % are spinal) anesthesia is used. Postoperative analgesia consist of IV PCA with hydromorphone, oxycodone extended release 10 mg q8 h × 12 doses, and oxycodone 5–15 mg q 2 h prn after the IV PCA is discontinued. Additional analgesics are celecoxib 200 mg BID × 8 doses, acetaminophen 100 mg q 6 h × 4 days, and gabapentin 200 mg q8 h × 12 doses. For the TKR patients with a femoral nerve catheter, ropivacaine 0.15 % is infused at 5 ml/h until 0600 POD2. Routine prn medications for nausea are ondansetron, procchlorperazine, and dimenhydrinate. Diphenhydramine is routinely used on a prn basis for pruritus. Both pathways target BID ambulation on POD1 followed by progressively more activity. For pharmacological deep venous thrombosis (DVT) prophylaxis, rivaroxaban 10 mg po daily is started on POD1 for 15 days.

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Liu, S.S., Buvanendran, A., Rathmell, J.P. et al. Predictors for moderate to severe acute postoperative pain after total hip and knee replacement. International Orthopaedics (SICOT) 36, 2261–2267 (2012). https://doi.org/10.1007/s00264-012-1623-5

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  • DOI: https://doi.org/10.1007/s00264-012-1623-5

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