Preemptive Opioid Sparing Analgesia in Total Hip and Knee Arthroplasty

Abstract

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.