Management of Postoperative Pain in Elective Hip and Knee Arthroplasty Surgery

Background:

Hip and knee arthroplasty surgeries are among the most painful surgical procedures, with half of patients reporting severe postoperative pain, Unrelieved postoperative pain is associated with diminished rehabilitation, delirium, disrupted sleep, and slower healing, The American Pain Society has published guidelines for optimal postoperative pain control, which many studies define as a pain score ≤ 4 of 10 (with 10 the highest) The guidelines recommend the use of around‐the‐clock, multimodal analgesia including a combination of acetaminophen, nonsteroidl antiinflammatories (NSAIDs), and narcotics. This combination produces significant reductions in postoperative pain scores, opioid use, and side effects. Studies report poor adherence to these guidelines, with resultant uncontrolled postoperative pain, Hospitalist management of orthopedic patients is increasing and offers an opportunity to improve postoperative pain management.

Methods:

We performed a retrospective chart review of patients who underwent elective hip (THA) or knee (TKA) arthroplasty at a major academic medical center from June 25, 2006, to December 31, 2007, Pain scores on a scale of —10 were abstracted from nursing notes for the first 3 days of hospitalization. Medications ordered and administered were recorded All narcotics received, including those by patient‐controlled analgesia (PCA) and patient‐controlled epidural analgesia (PCEA). were converted to oral morphine equivalents.

Results:

A team of 6 hospitalists and 4 orthopedists comanaged 34 THA and 66 TKA patients, Sixty‐seven percent of the patients were female, with an average age of 64 years. Ninety‐five percent of the patients received PCA or PCEA postoperatively. Seven percent of the patients received scheduled acetaminophen, 22% scheduled NSAIDs, and 8% scheduled narcotics. Six percent of the patients received the recommended scheduled multimodal therapy. On postoperative day (POD) 1, 73% of the patients had at least 1 pain score > 4. Of the 22 patients receiving scheduled NSAIDs, none reported pain scores > 4, and the average amount of morphine equivalent used was 118 mg, compared with 172 mg in the non‐NSAID group. On POD 2, 28% of patients had at least 1 pain score > 4, with none of the patients receiving NSAIDs reporting high scores. Narcotic use in the NSAID group averaged 65 mg, compared with 82 mg in the non‐NSAID group. Overall, 51% of the hospitalist notes mentioned pain control Forty percent of these notes deferred pain control to the orthopedic team.

Conclusions:

Postoperative orthopedic pain continues to be undertreated. Although patient‐controlled analgesic use is common, recommended scheduled multimodal therapy is not, Scheduled NSAID use is associated with lower pain scores and overall less use of narcotic medications. Significant room for improvement in pain awareness, guideline concordance, and pain treatment exists despite hospitalist involvement.

Author Disclosure:

J. Baker, none; J. Glasheen, none.