Best Practices
Total Knee Arthroplasty
All best practices are subject to change and may require modifications depending on a patient’s history and status. Healthcare practitioners should always defer to their clinical judgement and, whenever appropriate, consult with additional resources for further guidance.
| Preoperative | Intraoperative | Postoperative (Inpatient) | Discharge Strategies |
|---|---|---|---|
| •Acetaminophen 1g •NSAIDs (consider selective COX-2 inhibitors for fewer side effects) •Peripheral nerve blockade (eg. adductor canal block)^ | •Spinal anesthesia •May consider intrathecal morphine in select patients (consider in patients with underlying chronic pain or complex total knee arthroplasty) •Dexamethasone 0.1mg/kg •Periarticular injection by surgeon | •Consider continuing regional catheter, or readministering block •Hydromorphone 0.2mg IV q5-10min then as needed •Acetaminophen 650mg-1g q6h regularly scheduled •NSAIDs (PO Celecoxib 100-200mg BID) x 48hrs •Hydromorphone 2-4mg PO q3h as needed | MANAGEMENT OF PAIN W/O MEDICATION: •Automated cooling system (e.g. Game Ready) •Early physiotherapy •Ice •Relaxation techniques (breathing, meditation, mindfulness, etc.) CO-ANALGESICS: •Acetaminophen (maximum 4g/day) •NSAIDs (consider selective COX-2 inhibitors for fewer side effects and a prescription for increased compliance) OPIOID PRESCRIPTION:* Recommend: 30 tablets Range: 25-35 tablets For higher numbers, consider a.part-fill prescription |
^While several nerve blocks have been studied (fascia iliaca compartment block, pericapsular nerve group, quadratus lumborum, etc.), there is insufficient data on the superiority of one block over another. The recently published ICAROS trial suggests improved outcomes irrespective of type of nerve block versus no block.
*All tabs for discharge are oxycodone, 5mg. To convert this dosage to a different opioid drug, please visit this page. For conversions involving oxycodone, please note that it is 50% more potent than morphine. We encourage prescribers to consider discharge prescriptions of short-acting opioids at the lowest effective dose, with the lowest potency, for the shortest duration. Please note that current guidelines give a range of tabs. While we suggest prescribing the lowest effective dose possible, where clinical judgment indicates prescribing toward the higher range, we recommend using a part-fill prescription.
Before surgery, and at the surgical safety checklist time, the surgical and anesthesia team should work together to develop a multimodal pain management plan with active strategies to optimize perioperative pain management.
Healthcare practitioners are also encouraged to help patients set realistic expectations around pain management, including the use of prescription medications. Additional useful information to enhance recovery after surgery can be found at Enhanced Recovery Canada.
See our full disclaimer here.
References
Auyong DB, Allen CJ, Pahang JA, Clabeaux JJ, MacDonald KM, Hanson NA. Reduced Length of Hospitalization in Primary Total Knee Arthroplasty Patients Using an Updated Enhanced Recovery After Orthopedic Surgery (ERAS) Pathway. J Arthroplasty. 2015 Oct;30(10):1705-9.
Amundson AW, Johnson RL, Abdel MP, Mantilla CB, Panchamia JK, Taunton MJ, et al. A Three-arm Randomized Clinical Trial Comparing Continuous Femoral Plus Single-injection Sciatic Peripheral Nerve Blocks versus Periarticular Injection with Ropivacaine or Liposomal Bupivacaine for Patients Undergoing Total Knee Arthroplasty. Anesthesiology. 2017 06;126(6):1139-50.
Biswas A, Perlas A, Ghosh M, Chin K, Niazi A, Pandher B, et al. Relative Contributions of Adductor Canal Block and Intrathecal Morphine to Analgesia and Functional Recovery After Total Knee Arthroplasty: A Randomized Controlled Trial. Reg Anesth Pain Med. 2018 Feb;43(2):154-60.
Felix MMDS, Ferreira MBG, da Cruz LF, Barbosa MH. Relaxation Therapy with Guided Imagery for Postoperative Pain Management: An Integrative Review. Pain Manag Nurs. 2019 02;20(1):3-9.
Leegwater NC, Willems JH, Brohet R, Murgier J, Cailliez J, Wargny M, Chiron P, Cavaignac E, Laffosse JM. Cryotherapy With Dynamic Intermittent Compression Improves Recovery From Revision Total Knee Arthroplasty. J Arthroplasty. 2017 09;32(9):2788-91.
Prospect. Prospect Total Knee Arthroplasty Subgroup [Internet]. Switzerland: ESRA; 2020 [cited 2020 Jul 27]. Available From: https://archive.postoppain.org/sections/?root_id=47232§ion=8
Su EP, Perna M, Boettner F, Mayman DJ, Gerlinger T, Barsoum W, et al. A Prospective, Multi-Center, Randomised Trial to Evaluate the Efficacy of a Cryopneumatic Device on Total Knee Arthroplasty Recovery. J Bone Joint Surg Br. 2012 Nov;94(11 Suppl A):153-6.
Verret M, Lauzier F, Zarychanski R, Perron C, Savard X, Pinard AM, et al. Perioperative Use of Gabapentinoids for the Management of Postoperative Acute Pain: A Systematic Review and Meta-analysis. Anesthesiology. 2020 08;133(2):265-79.
Wainwright TW, Gill M, McDonald DA, Middleton RG, Reed M, Sahota O, et al. Consensus Statement for Perioperative Care in Total Hip Replacement and Total Knee Replacement Surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations. Acta Orthop. 2020 02;91(1):3-19.
Zeidan F, Emerson NM, Farris SR, Ray JN, Jung Y, McHaffie JG, et al. Mindfulness Meditation-Based Pain Relief Employs Different Neural Mechanisms Than Placebo and Sham Mindfulness Meditation-Induced Analgesia. J Neurosci. 2015 Nov 18;35(46):15307-25.
Zeidan F, Martucci KT, Kraft RA, Gordon NS, McHaffie JG, Coghill RC. Brain Mechanisms Supporting the Modulation of Pain by Mindfulness Meditation. J Neurosci. 2011 Apr 6;31(14):5540-8.
Treatment Altering Factors
Below are a few of the more common and/or impactful health factors that may result in deviation from the above best practices. Please note that the following list is not exhaustive and that the remarks for each factor are not surgery-specific. Healthcare practitioners should always defer to their clinical judgement and, if appropriate, consult with additional resources for further guidance. See our full disclaimer here.
Organ Dysfunction
Hepatic dysfunction/Excessive alcohol intake
| •In general: Limit or avoid acetaminophen altogether, depending on degree of hepatic dysfunction •Preoperative: Avoid or reduce dose of acetaminophen •Intraoperative: Decrease dose of opioids, benzodiazepines, meperdine •Postoperative: Reduce dose of acetaminophen •Discharge: Lower daily maximum dose of tramadol and increase dosing interval; avoid codeine |
Renal dysfunction
| •In general: Limit or avoid NSAIDs altogether, depending on degree of renal dysfunction •Preoperative: Avoid NSAIDs and use gabapentinoids cautiously •Intraoperative: Avoid morphine and meperidine •Postoperative: Avoid NSAIDs and use lower dose of gabapentin •Discharge: Lower daily maximum dose of tramadol and increase dosing interval; avoid codeine |
Patient Specific Factors
Advanced age
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| •Preoperative: Due to the frequency of multiple comorbidities in advanced age, anesthesia preoperative consult as needed to preoptimize. Also, manage anticoagulants where indicated; avoid long delays in hip fracture patients and practice preemptive analgesia •Intraoperative: Regional anesthesia and peripheral nerve blocks preferable where indicated •Postoperative: Regular dose acetaminophen; oral NSAIDs where indicated •Discharge: Consider minimum amount of opiates based on the surgical procedure, age and comorbidities |
Chronic pain and/or long-term opiate use
| •In general: May attempt to wean chronic opioids if surgery is to treat issues contributing to the chronic pain but otherwise continue chronic pain medication perioperatively if patient uses it •Preoperative: Anesthesia consult where indicated; continue preop opioids on day of surgery and give preemptive analgesia •Intraoperative: Regional anesthesia and peripheral nerve blocks preferable where indicated; use a multi-modal opioid sparing approach; may require higher doses of opioids to account for tolerance •Postoperative: Use a multi-modal opioid sparing approach; may require higher doses of opioids to account for tolerance; regular dose acetaminophen and oral NSAIDs where indicated •Discharge: Consider minimum amount of opiates based on the surgical procedure, age and comorbidities and avoid opioid dose escalation from preop, if possible |
History of difficulty with postop pain management
| •Consider regional anesthetic techniques, if feasible for specific surgical procedure |
Uncontrolled anxiety/depressive symptoms
| •Preoperative: Consider anxiolytics prior to administration of anesthetic •Discharge: While reviewing expected duration of opioid use, as well as opioid safety strategies including the appropriate storage and disposal of unused pills, should be standard practice, it is of paticular importance with patients who have uncontrolled anxiety/depressive symptoms Special note for paediatric surgeries: Given the risk of opioid misuse in youth with depressive symptoms, consider heightened opioid safety factors including reviewing with caregivers at discharge |
System Disorders
Coagulopathy
| •Avoid neuraxial techniques if any abnormal coagulation; consider following ASRA guidelines |
Obstructive sleep apnea
| •Preoperative: Use multi-modal analgesia; reduce or avoid use of gabapentinoids •Intraoperative: Reduce or avoid benzodiazepines; reduce doses of opioid medications •Postoperative: Use multi-modal analgesia; reduce use of opioids and gabapentinoids •Discharge: Reduce opioid dosing |