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Multi-modal approach manages pain at critical time points with few side-effects
Mayo Clinic surgeons have switched to an approach that relies on peripheral nerve blocks.
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Using peripheral nerve blocks as part of a multi-modal approach to pain management proved successful for managing postoperative pain in patients undergoing total knee replacement at the Mayo Clinic in Rochester, Minn.
Although complex, this approach is highly reproducible, according to Mark W. Pagnano, MD.
“This was a reliable way of addressing pain in the postoperative period,” Pagnano said at the 2009 Annual Current Concepts in Joint Replacement Spring Meeting.
Stay ahead of pain
This approach to pain management for total knee replacements (TKR) uses preoperative medications and regional anesthesia over parenteral narcotics.
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“The ways to do that are: be multimodal, so you stay below the threshold for side-effects; be preemptive, so you stay ahead of pain; and try to be more specific in addressing pain, whenever possible. Peripheral nerve blocks are better than epidural techniques, which are better than general anesthesia techniques.” Pagnano said.
In the preoperative period, the approach calls for using acetaminophen, a long-acting narcotic or an anti-inflammatory medication with or without gabapentin.
Nerve catheters
An indwelling femoral nerve catheter and a single-shot sciatic nerve block are placed preoperatively. Those blocks are performed either in the OR, for the first case of the day, or in a dedicated nerve-block room for subsequent cases. A short-acting spinal anesthetic is typically used for the intraoperative anesthesia.
Femoral nerve catheters are typically removed after 2 nights.
“The postoperative medication is given on a schedule, not just on an as-needed basis and consists of acetaminophen, an anti-inflammatory and tramadol,” Pagnano said, adding that he may supplement that with long- or short-acting narcotic medication for breakthrough pain.
In a matched series of 100 patients where the multi-modal approach with nerve blocks was compared to patient-controlled analgesia pumps, the multimodal pain management group’s Visual Analog Scale pain scores were lower at 3 days postoperative, he said.”
For more information:
- Mark W. Pagnano, MD, can be reached at the Mayo Clinic, 200 First St. SW, Rochester, MN 55944; 507-284-5276; e-mail: pagnano.mark@mayo.edu. He has no direct financial interest in any products or companies mentioned in this article.
References:
- Horlocker T, Kopp S, Pagnano MW, Hebl J. Analgesia for THA and TKA: a multimodal approach. J Am Acad Orthop Surg. 2006;14:126-135.
- Pagnano MW. Achieving the painless TKA: Be all you can be! #41. Presented at the 10th Annual Current Concepts in Joint Replacement Spring Meeting. May 17-20, 2009. Las Vegas.