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

Abstract

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.