Multimodal Pain Management for Major Joint Replacement Surgery

Abstract

Effective pain management for orthopedic major joint replacement is key to achieving earlier recovery, better functioning, and high rates of patient satisfaction. In an effort to decrease opioid dependency, practitioners are turning to multimodal pain management, which involves the use of multiple analgesic agents and techniques. In order to utilize this technique, a patient’s history of and preoperative consumption of medications to treat pain impacts the success of this regimen. Multimodal pain management involves the use of NSAIDS, acetaminophen, NMDA antagonists, gabapentin, serotonin inhibitors, regional techniques and opioids as needed. It is necessary for the nurse to understand the mechanism of pain and how the multimodal adjuncts target the pain response in order to benefit the patient’s perioperative course as well as their postoperative and discharge management.

Multimodal analgesia is superior to opiates alone after tibial fracture in patients with substance abuse history

“…[15][16][17][18][19] The pain after orthopaedic surgery is complex in nature, and appropriate management is important in allowing for early mobilization, resulting in reduced complications, such as blood clots, and subsequent better function. [17,19] Owing to the painful nature of the procedures that they perform, orthopaedic surgeons account for 7.7% of all opioid prescriptions, making orthopaedics one of the highest prescribing specialties of opiates. [20,21] The use of multimodal analgesia has been associated with a decrease in opiates, although the decrease is often statistically but not clinically significant.…”

Benefits of Implementing an Enhanced Recovery After Surgery Protocol in Ambulatory Surgery

“…6 Other aspects of multimodal pain management including scheduled acetaminophen and celecoxib likely also contribute to this continued decrease in pain response and decreased long-term opioid prescription. 6 Peripheral nerve block anesthesia, such as IPACK and FNB, have been shown to be effective in treatment of acute pain. 7 However, there are also associated risks, such as vascular injury, prolonged numbness, and possible systematic toxicity.…”

“… 6 Other aspects of multimodal pain management including scheduled acetaminophen and celecoxib likely also contribute to this continued decrease in pain response and decreased long-term opioid prescription. 6 …”

“…Decreasing the pain response in the immediate postoperative period helps decrease the secondary inflammatory response that leads to increased long-term opioid need. 6 Other aspects of multimodal pain management including scheduled acetaminophen and celecoxib likely also contribute to this continued decrease in pain response and decreased long-term opioid prescription. 6 Peripheral nerve block anesthesia, such as IPACK and FNB, have been shown to be effective in treatment of acute pain.…”

Position Statement: Acute Perioperative Pain Management Among Patients Undergoing Orthopedic Surgery by the American Society for Pain Management Nursing and The National Association of Orthopaedic Nurses

“…These assessments must include assessing sedation and consideration of individualized risk factors ( Chou et al, 2016 ;Pasero et al, 2016 ). • To achieve optimal pain management, utilize multimodal analgesia, including the intentional use of appropriate pharmacologic and nonpharmacologic techniques, and adherence to Enhanced Recovery After Surgery protocols ( Chou et al, 2016 ;Echeverria-Villalobos et al, 2020 ;Goode et al, 2019 ;Institutes of Medicine, 2011 ;Montgomery & McNamara, 2016 ;Tick et al, 2018 ). • Organizations are responsible for developing standardized policies and providing appropriate pain management education and training for clinicians, patients, and families ( Hsu, 2019 ;The Joint Commission, 2021 ).…”