• A Clinical Practice Guideline: Pre-Emptive Opioid Sparing Analgesia in Total Hip and Knee Arthroplasty

      Bob-Manuel, Bateim; Pellegrini, Joseph (2019-05)
      Background: Traditionally, postoperative pain has primarily been treated using opioids. Use of opioids as the “mainstay” of pain management can result in psychological addiction and adverse effects, such as nausea and vomiting, sedation, dizziness, constipation and respiratory depression all of which may delay patient discharge. effects. Preemptive multimodal analgesia involves the introduction of an analgesic pain regimen before the onset of noxious stimuli such as the surgical incision. Recent understandings in pre-emptive analgesia have defined it as an intervention given before incision or surgery, given that it is more effective than the same treatment administered after incision or surgery. Multimodal pain management solutions are associated with fewer opioid-related side effects, along with fewer interruptions to physical therapy. Additionally, this approach interchanges opioids pharmaceuticals with non-opioid analgesics such as acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDS), selective cyclooxygenase-2 (COX-2) inhibitors, and gabapentinoids. Local Problem: This Doctor of Nursing Practice project aimed to develop a clinical practice guideline to serve as a guidance for anesthesia providers in regards with the initiation of preemptive opioid sparing analgesia for total knee and hip arthroplasties at a large community hospital in Maryland. Currently there is no guidelines for the use of administration of preoperative analgesia for the TKA/THA patient at this institution. Intervention: The development of the guideline occurred in three phases. Phase one encompassed the recruitment of stakeholders and initial drafting of the clinical practice guideline. Phase two included the utilization of The Appraisal of Guidelines for Research & Evaluation II (AGREE II) tool to assess the quality of the guideline. The finalized guideline was presented at Grand Rounds to the anesthesia department staff. A Practitioner Feedback Questionnaire (PFQ), was handed out at the beginning to all in attendance for evaluation of the CPG. Lastly, phase three encompassed the graduate students presenting final approved guideline in entirety to the anesthesia department, a performance of data analysis/evaluation, submission of finalized manuscript to the stakeholders for review, and final presentation of doctoral project in the form of a poster presentation. Results: Domain scores from the AGREE II tool ranged from 71.6 to 100%. The highest rated domain was “Editorial Independence” at 100%. Other strongly scored domains included “Scope and Purpose” at 94.4%, “Clarity of presentation” at 83.3% and “Rigour of Development” at 84.7%. The lowest rated domains included “Stakeholder Involvement” at 47% and “Applicability” at 80.4%. The students received 74% return rate of the Practitioner Feedback Questionnaires at the presentation (n=29). Most anesthesia providers felt the guideline should be approved for practice (95.5%), would use it in their own practice (100%) and would apply the recommendations to their patients (100%). Conclusions: The cumulative result of multimodal analgesia is a promising alternative that may reduce needs for high doses and dependence on opioids along with any potential associated adverse effects. The total cost of utilizing the medications mentioned in the CPG would be roughly $6,300 in one year, which can result to a 73% savings when compared to their current practice.
    • Preemptive Opioid Sparing Analgesia in Total Hip and Knee Arthroplasty

      Pulido, Lia A.; Gonzalez, Michelle; Pellegrini, Joseph (2019-05)
      Background Total Knee and Total Hip Arthroplasty procedures have been reported to be very painful in the first 48 hours postoperatively. Undermanaged postoperative pain can significantly limit rehabilitation, recovery, increase patient dissatisfaction, increase healthcare costs, and lead to chronic pain. Local Problem Although opioids are included in perioperative analgesic management for joint arthroplasty, side effects such as sedation, respiratory depression, nausea, vomiting, ileus, and pruritus remain major issues. A large tertiary hospital in Maryland performs high volumes of procedures performed annually, and with the expectation to continually provide effective postoperative pain management, this facility expressed interest in the need for a clinical practice guideline. Research has shown that a pre-emptive multimodal approach, a combination of non-opioid drugs administered prior to surgical incision, produces synergistic analgesia, while decreasing side effects. Interventions The purpose of this quality improvement project was to develop a clinical practice guideline for preemptive opioid sparing analgesia through the use of preoperative administration of Acetaminophen, Gabapentin, and Celebrex for patients undergoing elective lower extremity arthroplasties. The development of the guideline was guided by the Knowledge-to-Action Framework and occurred over three phases. A literature review was completed on multimodal and preemptive analgesia for patients undergoing lower extremity arthroplasty. Three medications were frequently studied; therefore, each group member focused on one drug, and later combined all the literature data to formulate a draft clinical practice guideline. During phase one, a draft clinical practice guideline was introduced to stakeholders. The guideline was then evaluated by stakeholders using the AGREE II tool, a valid and reliable tool was used to assess variability, rigor and transparency of quality of the guideline. In phase three, the Practitioner Feedback Questionnaire was utilized to gain feedback regarding the quality of the guideline from the Anesthesia Department. Results The results of the AGREE II tool’s domains scores ranged from 71.6 to 100%, with 100% (n=29) of reviewers recommending the guideline for implementation into practice. The results for the Practitioner Feedback Questionnaire were as followed: the majority of respondents were CRNAs (59%), SRNAs (24%), and physician anesthesiologists (17%). Sixteen out of twenty-three items had a response of “strongly agree.” One hundred percent of the participants agreed that the rationale for the CBG was clear, and that the methodology, review of literature, and interpretation of evidence were identified to be pertinent and valid. Conclusions Inadequate postoperative pain management can significantly limit rehabilitation recovery, decrease patient dissatisfaction, increase healthcare costs, and complications. Traditional analgesics such as opioids are often associated with undesirable side effects. A clinical practice guideline for preemptive opioid sparing analgesia through the use of preoperative administration of Acetaminophen, Gabapentin, and Celebrex have shown to be effective in improving postoperative pain, lowering overall narcotic consumption and side effects, reducing hospital stay, and improving function while minimizing complications.