Joint replacement is a proven remedy for many kinds of joint dysfunction, but the pain experienced by the patient after the surgery must also be addressed. To help reduce postoperative pain, UCSF takes a unique, multimodal and multidisciplinary approach.
Peter Koo, PharmD, is a UCSF health sciences clinical professor of pharmacy, as well as a pharmacist specialist in pain management. "Our combination of regional nerve blocks, systemic medications and physical manipulation is quite effective," says Koo. "That's because we have come to appreciate the very serious nature of pain, and want to address it aggressively. Patients shouldn't have to suffer."
Koo advises physicians to be attentive in managing pain in their own practices. He recommends that physicians take a multimodal approach to pain management during surgery, immediately after surgery and during the recovery period.
"Managing postoperative pain will require close monitoring of the patient on a regular and frequent basis," says Koo. "Patients who require multiple analgesics may need to have their analgesics consolidated and tapered, starting after discharge from the hospital, as they recover to health."
Koo advises that nerve pain be treated with analgesic adjuncts, rather than with more opiate analgesics. Often, nerve pain is best managed with membrane-stabilizing agents, such as anticonvulsants and antidepressants. If the pain becomes too difficult to manage, Koo recommends referring the patient to a pain management specialist for consultation and management.
When joint surgery is performed at UCSF Medical Center, a multidisciplinary team of physicians, nurse practitioners, physician assistants, nurses and pharmacists at UCSF's Arthritis and Joint Replacement Center focuses on reducing pain for patients at the first evaluation and throughout the hospitalization and recovery process.
"We ask the patients about pain management during their preoperative evaluation, so we can start talking about what pain control needs they might have after the surgery," says Koo. "And on the day before the surgery, patients meet with the anesthesiologist to determine the best approach for anesthesia and pain control during the surgery itself."
All patients receive referrals to the UCSF Osher Center for Integrative Medicine, which offers regular classes on preparing for surgery, including use of relaxation techniques to manage and reduce pain. Patients are also required to attend a preoperative class given by an arthroplasty nurse practitioner, where they learn about anesthesia, nerve blocks and pain medications, as well as postsurgical precautions and clot prevention.
During the actual surgery, anesthesiologists may use peripheral nerve or epidural blocks for anesthesia, so that pain is blocked at the site of surgery. This emphasis on regional anesthesia and conscious sedation helps reduce the need for general anesthesia, which tends to reduce postoperative side effects and length of time in the recovery room, and to speed overall recovery time in the hospital.
Because pain during the first 24 to 48 hours after surgery can be quite intense, regional nerve block catheters are left in for at least one day after surgery to help control pain continuously. Patients are also given patient-controlled analgesia (PCA) for self-managed pain control. On the second day, the catheter is removed, but PCA is continued, along with starting an oral opiate analgesic regimen. The PCA pump has a safety lockout mechanism that prevents accidental overdosing. The overall focus is to control the pain while reducing the amount of narcotic medication required by the patient, as well as the associated side effects.
By the third day, many patients are on a combination of oral analgesics in preparation for going home. Ice may also be used for decreasing pain and swelling after surgery. The knee patient may be prescribed a continuous passive motion (CPM) machine for use at home, if the surgeon feels there is some benefit from extended use. "CPM helps the newly replaced knee joint stay mobile, which improves the patient's rate of recovery," says Koo. Physical therapists also work with patients to help them move and navigate daily activities—such as getting in and out of bed and climbing stairs—in the safest, most secure and most comfortable way.
All joint replacement patients are sent home with a prescription for pain control. Some patients receive two prescriptions: one strong medication for the initial week after surgery and a second, less potent prescription for the following weeks. Other patients are advised to simply take a smaller dose of the same prescription when the pain is less severe. "By the fourth or fifth week, most patients may only require minimal amounts of pain medication," says Koo.
Jane Pun, R.N., NP, in the UCSF Arthritis and Joint Replacement Center says that some patients present challenges regarding pain management. "If they're already taking pain medications like OxyContin or Percocet preoperatively, they may have a harder time getting their pain under control perioperatively," says Pun. "Most of these patients have had previous joint replacement surgeries. We recommend that these patients maintain their normal regimen prior to surgery, and after surgery that they reduce their pain medications gradually, as tolerated, in order not to put them into opiate withdrawal."
Patients who are still using high levels of opiate medications by the sixth week are counseled during their post-surgical checkup about weaning off the drugs. If patients suffer chronic pain, they might be recommended for an evaluation by a pain management specialist.
Peter Koo, PharmD, can be contacted at (415) 476-3055.
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