Patient-controlled oral analgesia for postoperative pain management following total knee replacement

Comparison of adductor canal block and femoral nerve block for pain management in anterior cruciate ligament reconstruction: A meta-analysis of randomized controlled trials

OBJECTIVE

To compare the efficacy of adductor canal block and femoral nerve block for pain management in patients with anterior cruciate ligament reconstruction.

METHODS

A computerized search was performed in the database of PubMed, Embase, Web of Science and Cochrane Library for randomized controlled trials. The outcome measures included visual analog scale, morphine consumption, quadriceps strength, length of hospitalization and postoperative adverse events. The risk of bias of randomized controlled trials was assessed according to the Cochrane Risk of Bias Tool. All quantitative syntheses were completed using STATA version 14.

RESULTS

Seven randomized controlled trials involving a total of 643 patients were included in our meta-analysis. The present meta-analysis indicated that there were no significant differences between the 2 groups in terms of postoperative pain score, opioid consumption, length of hospitalization or adverse effects after anterior cruciate ligament reconstruction. However, adductor canal block showed superior quadriceps strength and range of motion in the early postoperative period.

CONCLUSION

Adductor canal block shows similar and adequate analgesia compared to the femoral nerve block in anterior cruciate ligament reconstruction and adductor canal block can preserve a higher quadriceps strength and better range of motion.

Factors associated with success and failure of patient-controlled oral analgesia after total hip and knee arthroplasty: a historical comparative cohort study

PURPOSE

Patient-controlled oral analgesia (PCOA) is a novel method of oral opioid administration using set doses of short-acting oral opioids self-administered by patients with a "lockout" period as part of a multimodal regimen. Failure of PCOA can result in severe postoperative pain necessitating use of intravenous patient-controlled analgesia (IV-PCA) with its potential complications. This study evaluated factors related to success or failure of PCOA following total hip arthroplasty (THA) and total knee arthroplasty (TKA).

METHODS

We conducted a retrospective cohort study of all adults who underwent THA and TKA at our institution by extracting data from the proprietary database of our acute pain service. Patient, anesthetic, and surgical variables associated with PCOA failure defined as inadequate analgesia requiring conversion to IV-PCA within 24 hr following THA and TKA were evaluated. Univariable and multivariable logistic regression analyses were performed to identify predictors of PCOA failure.

RESULTS

Of the 926 patients who underwent THA or TKA (n = 411 and 515, respectively), 147 (15.9%) patients (67 THA and 80 TKA patients) had PCOA failure with moderate-to-severe pain. Multivariable regression analysis showed that PCOA failure occurred in those with younger age (adjusted odds ratio [aOR] per year of age, 0.97; 99% CI, 0.95 to 0.99; P < 0.001), preoperative chronic use of controlled-release opioids (aOR, 3.45; 99% CI, 1.60 to 7.35; P < 0.001), and with the use of general anesthesia vs spinal anesthesia (aOR, 2.86; 99% CI, 1.20 to 6.84; P = 0.002).

CONCLUSION

The use of PCOA provides adequate analgesia to a majority of patients undergoing THA and TKA. Factors predictive for PCOA failure should be considered when choosing the primary breakthrough analgesic modality following THA/TKA.

The Efficacy and Safety of Opioids in Total Joint Arthroplasty: Systematic Review and Direct Meta-Analysis

BACKGROUND

Opioids are frequently used to treat pain after total joint arthroplasty (TJA). The purpose of this study was to evaluate the efficacy and safety of opioids in primary TJA to support the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Hip Society, Knee Society, and the American Society of Regional Anesthesia and Pain Management.

METHODS

The MEDLINE, EMBASE, and Cochrane Central Register of controlled trials were searched for studies published before November 2018 on opioids in TJA. All included studies underwent qualitative and quantitative homogeneity testing followed by a systematic review and direct comparison meta-analysis to assess the efficacy and safety of opioids.

RESULTS

Preoperative opioid use leads to increased opioid consumption and complications after TJA along with a higher risk of chronic opioid use and inferior patient-reported outcomes. Scheduled opioids administered preemptively, intraoperatively, or postoperatively reduce the need for additional opioids for breakthrough pain. Prescribing fewer opioid pills after discharge is associated with equivalent functional outcomes and decreased opioid consumption. Tramadol reduces postoperative opioid consumption but increases the risk of postoperative nausea, vomiting, dry mouth, and dizziness.

CONCLUSION

Moderate evidence supports the use of opioids in TJA to reduce postoperative pain and opioid consumption. Opioids should be used cautiously as they may increase the risk of complications, such as respiratory depression and sedation, especially if combined with other central nervous system depressants or used in the elderly.

The Effect of Patient-Controlled Oral Analgesia for Acute Abdominal Pain after Discharge

BACKGROUND

During hospitalization, patients who were admitted with acute abdominal pain must be prepared to care for themselves at home after discharge to continue established treatment, promote recovery, and avoid readmission.

AIMS

Our aim was to investigate the quality of pain management after discharge, when patient-controlled oral analgesia was compared with standard care for patients admitted to hospital with acute abdominal pain. The primary outcome measures were pain intensity and patient perception of care. The secondary outcome measures were pain interference with activity, affective experiences, side effects, and use of analgesics.

DESIGN

A questionnaire study measuring the effect of an intervention on patient-controlled oral analgesics.

SETTINGS

An emergency department and a surgical department in Denmark.

PARTICIPANTS

Patients admitted to hospital with acute abdominal pain.

METHODS

A pre- and postintervention study was conducted in an emergency department and a surgical department with three subunits. Data were collected using a Danish modified Revised American Pain Society Patient Outcome Questionnaire with five subscales (scale 0-10) completed in weeks 1 and 4 after discharge.

RESULTS

In total, 117 patients were included. The median scores at week 1 and week 4 in the control and intervention groups were, respectively, 2/1 and 1/0 on the pain subscale (p = .11/.16), 3/0 and 3/0 on the activity subscale (p = .19/.80), 1/0 and 0/0 on the emotional subscale (p = .02/.72), 1/0 and 1/0 on the side effect subscale (p = .95/.99), and 8/5 and 7/7 on the patient perception subscale (p = .35/.49). There was no significant difference in the use of analgesics at week 1.

CONCLUSIONS

Patient-controlled oral analgesia during the hospital stay did not improve the quality of pain management after discharge.

Patient-directed self-management of pain (PaDSMaP) compared to treatment as usual following total knee replacement; a randomised controlled trial

Background

Self-administration of medicines by patients whilst in hospital is being increasingly promoted despite little evidence to show the risks and benefits. Pain control after total knee replacement (TKR) is known to be poor.

The aim of the study was to determine if patients operated on with a TKR who self-medicate their oral analgesics in the immediate post-operative period have better pain control than those who receive their pain control by nurse-led drug rounds (Treatment as Usual (TAU)).

Methods

A prospective, parallel design, open-label, randomised controlled trial comparing pain control in patient-directed self-management of pain (PaDSMaP) with nurse control of oral analgesia (TAU) after a TKR. Between July 2011 and March 2013, 144 self-medicating adults were recruited at a secondary care teaching hospital in the UK. TAU patients (n = 71) were given medications by a nurse after their TKR. PaDSMaP patients (n = 73) took oral medications for analgesia and co-morbidities after two 20 min training sessions reinforced with four booklets. Primary outcome was pain (100 mm visual analogue scale (VAS)) at 3 days following TKR surgery or at discharge (whichever came soonest). Seven patients did not undergo surgery for reasons unrelated to the study and were excluded from the intention-to-treat (ITT) analysis.

Results

ITT analysis did not detect any significant differences between the two groups’ pain scores. A per protocol (but underpowered) analysis of the 60% of patients able to self-medicate found reduced pain compared to the TAU group at day 3/discharge, (VAS -9.9 mm, 95% CI -18.7, − 1.1). One patient in the self-medicating group over-medicated but suffered no harm.

Conclusion

Self-medicating patients did not have better (lower) pain scores compared to the nurse-managed patients following TKR. This cohort of patients were elderly with multiple co-morbidities and may not be the ideal target group for self-medication.

Trial Registration

ISRCTN10868989. Registered 22 March 2012, retrospectively registered.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3146-2) contains supplementary material, which is available to authorized users.

Absorption of ibuprofen orodispersible tablets in early postoperative phase - a pharmacokinetic study

OBJECTIVE

Patient-controlled oral analgesia has gained popularity in postoperative pain management. Anesthesia and surgery delay gastrointestinal tract function and this may therefore decrease bioavailability of drugs taken by mouth. To hasten absorption, an orodispersible ibuprofen tablet has been developed. In this study, we evaluated the pharmacokinetics and feasibility of orodispersible ibuprofen tablets in spine surgery patients.

METHODS

The study design was a prospective clinical trial where each patient served as her/his own control. Fifteen patients aged 19-75 years were given two orodispersible ibuprofen 200 mg tablets the day before surgery and two more tablets immediately after surgery. Blood samples for ibuprofen concentrations were taken at intervals for 6 hours following pre- and postsurgical administration of ibuprofen.

RESULTS

The mean preoperative area under time-concentration curve for ibuprofen (AUC_0-360) was 4806 (SD 1104) min·mg/L, and after surgery it was 2141 (583) min·mg/L (mean difference 2664, 95% CI for difference 2003 to 3325, p < .001). The mean of the maximum preoperative plasma concentration of ibuprofen was three times higher, 26.7 (7.7) mg/L, than the postoperative value of 8.6 (2.1) mg/L (mean diff. 18.1, 95% CI 13.9 to 22.4, p < .001). Times to maximum concentration were similar pre- and postoperatively at 155 (58) minutes and 169 (113) minutes (p = .67). No serious or unexpected adverse events were recorded.

CONCLUSIONS

While orodispersible ibuprofen tablets were feasible, ibuprofen absorption decreased immediately after surgery compared to the day before surgery. Thus, further studies are needed to establish the adequate initial postoperative dose.

Patient-controlled oral analgesia for acute abdominal pain: A before-and-after intervention study on pain intensity and use of analgesics

AIM

To compare the use of patient-controlled oral analgesia with nurse-controlled analgesia for patients admitted to hospital with acute abdominal pain. The primary outcome measure was pain intensity. The secondary outcome measures were the use of analgesics and antiemetics.

BACKGROUND

Inadequate pain management of patients with acute abdominal pain can occur during hospital admission. Unrelieved acute pain can result in chronic pain, stroke, bleeding and myocardial ischemia.

METHODS

A before-and-after intervention study was conducted in an emergency department and a surgical department with three subunits. Data were collected from medical charts and analyzed using chi-squared and Kruskal-Wallis tests.

RESULTS

A total of 170 patients were included. The median pain intensity score, using the numeric ranking scale, was 2.5 and 2 on Day 2 (p = 0.10), 2 and 2 on Day 3 (p = 0,40), 2.5 and 0 on Day 4 (p = 0.10), 2 and 0 on Day 5 (p = 0.045) in the control and intervention group, respectively. The percentage of patients receiving analgesics was 93 and 86 on Day 2 (p = 0.20), 91 and 75 on Day 3 (p = 0.02), 89 and 67 on Day 4 (p = 0.009) and 80 and 63 on Day 5 (p = 0.39). The use of antiemetics was similar in the two groups.

CONCLUSION

Patient-controlled oral analgesia significantly reduced the numerical ranking pain scale score on Day 5 and the consumption of analgesics on Days 3 and 4 after hospital admission. Patient-controlled oral analgesia is feasible as pain management for patients, but only with minor impact on experienced pain intensity and use of analgesics.

Perioperative Pain Management in Hip and Knee Arthroplasty

Total hip and knee arthroplasty is associated with significant perioperative pain, which can adversely affect recovery by increasing risk of complications, length of stay, and cost. Historically, opioids were the mainstay of perioperative pain control. However, opioids are associated with significant downsides. Preemptive use of a multimodal pain management approach has become the standard of care to manage pain after hip and knee arthroplasty. Multimodal pain management uses oral medicines, peripheral nerve blocks, intra-articular injections, and other tools to reduce the need for opioids. Use of a multimodal approach promises to decrease complications, improve outcomes, and increase patient satisfaction after hip and knee arthroplasty.

Nurses' Perceptions and Attitudes Toward Use of Oral Patient-Controlled Analgesia

Patient-controlled analgesia (PCA) administered intravenously is a generally well-accepted therapy by nurses and patients. PCA devices are now available for oral medications, allowing patients to self-administer pain pills without requesting them from the nurse. Successful introduction of new pain medication delivery devices can depend on nurses' knowledge and attitudes. The aim of this institutional review board approved project was to evaluate nurses' perceptions and attitudes toward using an oral PCA device for patients' pain. A 4-week study was designed and conducted at an academic medical center on an orthopedic unit and a women's health unit. Nurse participants received education on using the oral PCA device and were invited to complete a pre- and poststudy knowledge and attitude survey regarding pain management. Nurses and patients also completed a questionnaire about perceptions related to using the oral PCA device. Findings showed that nurses' attitudes toward using the oral PCA device were less favorable than those of patients, suggesting that nurses may require additional education for acceptance of this device. Results from 37 nurses showed improvement in overall knowledge and attitudes, from 70.8% pretest to 74.2% post-test. Although improvement was not statistically significant (p = .1637), two items showed significant improvement. Knowledge about the effectiveness of NSAIDS was 27.5% pretest compared with 60.0% post-test (p = .0028); and understanding about use of opioids in patients with a history of substance abuse was 50% pretest compared with 70% post-test (p = .0531). Helping nurses overcome the perceived barriers to use of an oral PCA device has potential implications for better pain management as well as enhanced patient satisfaction.

Patient-controlled oral analgesia versus nurse-controlled parenteral analgesia after caesarean section: a randomised controlled trial

We assessed the effectiveness of early patient-controlled oral analgesia compared with parenteral analgesia in a randomised controlled non-inferiority trial of women undergoing elective caesarean section under regional anaesthesia. Seventy-seven women received multimodal paracetamol, ketoprofen and morphine analgesia. The woman having patient-controlled oral analgesia were administered four pillboxes on the postnatal ward containing tablets and instructions for self-medication, the first at 7 h after the spinal injection and then three more at 12-hourly intervals. Pain at rest and on movement was evaluated using an 11-point verbal rating scale at 2 h and then at 6-hourly intervals for 48 h. The pre-defined non-inferiority limit for the difference in mean pain scores (patient-controlled oral analgesia minus parenteral) was one. The one-sided 95% CI of the difference in mean pain scores was significantly lower than one at all time-points at rest and on movement, demonstrating non-inferiority of patient-controlled oral analgesia. More women used morphine in the patient-controlled oral analgesia group (22 (58%)) than in the parenteral group (9 (23%); p = 0.002). The median (IQR [range]) number of morphine doses in the patient-controlled oral analgesia group was 2 (1-3 [1-7]) compared with 1 (1-1 [1-2]); p = 0.006) in the parenteral group. Minor drug errors or omissions were identified in five (13%) women receiving patient-controlled oral analgesia. Pruritus was more frequent in the patient-controlled oral analgesia group (14 (37%) vs 6 (15%) respectively; p = 0.03), but no differences were noted for other adverse events and maternal satisfaction. After elective caesarean section, early patient-controlled oral analgesia is non-inferior to standard parenteral analgesia for pain management, and can be one of the steps of an enhanced recovery process.

Patient directed self management of pain (PaDSMaP) compared to treatment as usual following total knee replacement: study protocol for a randomized controlled trial

BACKGROUND

In 2009, 665 patients underwent total knee replacements (TKRs) at the Norfolk and Norwich University Hospitals NHS Foundation Trust (NNUH), representing nearly 1% of the national total. Pain control following the operation can be poor, and this can cause poor mobilization and potential long-term adverse events. Although high levels of pain are not associated with patient dissatisfaction, brief periods of pain may lead to neuronal remodeling and sensitization. Patient controlled oral analgesia (PCOA) may improve pain relief; however, the evidence to date has been inconclusive. Patient directed self management of pain (PaDSMaP) is a single center randomized controlled trial, which aims to establish if patient self-medication improves, or is equivalent to, treatment as usual and to create an educational package to allow implementation elsewhere.

METHODS/DESIGN

Patients eligible for a TKR will be recruited and randomized in the outpatient clinic. All patients will undergo their operations according to normal clinical practice but will be randomized into two groups. Once oral medication has commenced, one group will have pain relief administered by nursing staff in the usual way (treatment as usual; TAU), whilst the second group will self manage their pain medication (patient directed self management of pain; PaDSMaP). Those recruited for self-medication will undergo a training program to teach the use of oral analgesics according to the World Health Organization (WHO) pain cascade and how to complete the study documentation. The primary endpoint of the trial is the visual analogue scale (VAS) pain score at 3 days or discharge, whichever is sooner. The follow-up time is 6 weeks with a planned trial period of 3 years. The secondary objectives are satisfaction with the management of patient pain post-operatively whilst an inpatient after primary TKR; overall pain levels and pain on mobilization; satisfaction with pain management information provided; global outcomes, such as quality of life (QOL) and activities of daily living (ADLs); time to mobilization and whether time to mobilization is associated with frequency of adverse events, improvements in QOL, ADLs and pain at 6 weeks after the operation; incidence of adverse events; quantity and type of pain medications used whilst an inpatient; the acceptability of PaDSMaP and/or TAU protocols for patients and the healthcare professionals involved in their care; to investigate the health-related costs associated with a PaDSMaP system; and to estimate the cost-effectiveness of PaDSMaP compared to TAU.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN: 10868989.

Nursing knowledge and beliefs regarding patient-controlled oral analgesia (PCOA)

Patient-controlled oral analgesia (PCOA) allows patients to self-administer oral opioids for pain management. Advantages of PCOA include improved pain control with lower doses of opioids, decreased length of stay, increased patient satisfaction, and better functional outcomes than conventional nurse-administered oral analgesia. Sucessful PCOA programs are well described in the literature. However, nurses have concerns about allowing patients to self-administer opioids. The purpose of this study was to identify nurses' knowledge and beliefs regarding PCOA. Nurses who work at the Holland Orthopaedic and Arthritic Centre were asked to complete a survey exploring their beliefs regarding PCOA. The nurses were asked to complete the same survey twice: before an education program in February 2010, and 3 months after implementation of PCOA in June 2010. In February 2010, 74 nurses and in June 2010, 32 nurses participated in the survey. Some nurses (18%) had previous experience with PCOA. At both the pre-education and the postimplementation times, nurses thought that the PCOA program reduced wait times for analgesics and improved patient satisfaction with pain management. Before program implementation, negative beliefs included that patients on the PCOA program would lose their analgesics, would give their analgesics to visitors or other patients, and were at risk for having their analgesics stolen and that the nurse was liable if the patient's analgesics were lost or stolen. After program implementation, no nurse believed that patients would lose their analgesics or give their analgesics to visitors or other patients or that they were liable for lost or stolen analgesics. However, nurses continued to think that patients were at risk for having their analgesics stolen. We found that nurses were concerned that analgesics could be lost, misused, or stolen and that they would be liable for lost analgesics. These findings were consistent with literature discussing patients' outcomes regarding PCOA. However, after education and experience these concerns decreased or resolved. It is important to address these concerns before PCOA program implementation.