Pain management following a total knee replacement

A good nursing care is very important contributing factor for better outcome after major surgical procedure. Patients require high standard of nursing care particularly after orthopaedic surgery (Hilton 2004).All nurses get exposure to post operative recovery room and ward during their training rotation period to learn about various aspects of nursing care required immediately after major surgery. Rotation given to the student helps student understanding clinical application of theoretical knowledge. Students follow their seniors and observe them undertaking various tasks. One of the students, Miss John, posted in post operative ward, under her rotation programme designed to obtain clinical experience got opportunity to observe postoperative care of Mr. Evans who was scheduled for right total Knee replacement.

On Arrival of Mr.Evans in the ward, she observed the staff nurse identifying him and asking him pre-operative questions. Staff nurse asked her specially about his perception of pain and to grade it at a number between 1 and 10.Mr Evans was explained about scale of pain that 0 means no pain  and 10 means worst pain. Mr.Evans put his current pain at 6 level. He was also asked about at what level of pain he would be comfortable. Mr.Evans told the nurse that the number would be 3.He was asked to describe the character of pain whether it was aching, burning, throbbing, pulling or sharp cutting and explained about plan to manage his post operative pain, as pain was his one of the major concerns of Mr.Evans. After taking vital data of Mr. Evans and completing pre operative notes by staff nurse, she saw him being taken to operation theatre.
She was taught that patients after undergoing operative procedure are monitored in a recovery room before shifting them to ward, as the operative procedure is a stressful condition, making patients prone to complications. Any operative condition is a stress to human body with liberation of endogenous substances from body and initiation of inflammatory cascade at surgical site leading to unpleasant experience of pain of varying intensity by patients. Pain is generated with stimulation of pain receptors in the body, and further conducted through nerves to spinal cord. From spinal cord pain is transmitted with the help of special tracts to thalamus in the brain where pain is perceived. There are two types of fibers in the body conduction pain sensation. One is fast fibers that recognizes intense pain and conducts it quickly, while another is large fiber conducting chronic (long standing) pain. Pain is a perception, having physiological or psychological nature of generation. Pain can be classified in to coetaneous, visceral, somatic or neuropathic according to its site of origin.

Although pain is a defense mechanism of body, its detrimental effects on body leads physicians to control it by various means. Postoperative-pain has adverse systemic effects in the form of cardiovascular, pulmonary, thromboembolic and gastrointestinal complication and local adverse effects. It also produces local complication in the form of weakness of limb, delayed wound healing, reflex sympathetic dystrophy. Uncontrolled pain can produce anxiety and sometimes depression creating a psychological trauma to patient. Its detrimental effects delays ambulation and physiotherapy consequently prolonging hospitalization and rehabilitation. Poor management of pain in post -operative period may lead to litigation against health care provider.
    After, two hours in operation theatre after completion of right total knee replacement, she saw Mr. Evans brought from operation theatre accompanying by anaesthetist. On arriving the reserved room for Mr. Evans in recovery, she observed anaesthetist providing information to staff nurse about the patient and operative events, while nurse applying oxygen mask, electrocardiography monitor, pulseoxymeter and blood pressure cuff to Mr. Evens.
Anaesthetist explained staff nurse briefly that Mr. Evens had been operated for right total knee replacement surgery under epidural anaesthesia uneventfully with 1.5 liter of fluids infused in theatre. As Mr. Evens didn’t have any operative procedure done before, he was very much concerned about post operative pain and has been explained about pain management in detail. Mr. Evans had a dose of analgesic and anxiolytic before operation and was put on mild sedation during operative procedure. Anaesthtist added that Mr. Evans didn’t have any past history of medical condition or any significant personal history.
Anaesthetist confirmed the vital data on monitor and asked patients how he felt especially about his pain. Mr. Evans replied that he didn’t have any pain and staff nurse entered this as a 0 in visual analogue scale .Anesthetist checked the infusion pumps prepared for Mr. Evans. One infusion pump was prepared to give local anaesthetic ropivacine in 0.2percent concentration to give at the rate of 3 to 7 ml/hr through epidural catheter. Another infusion pump contained opiates analgesic morphine in 1mg/ml preparation to be given in the form of patients controlled analgesia.
Staff nurse attached infusion pump containing ropivacaine to epidural catheter filter after checking catheter and started with the rate of 2 ml/hr on anesthetist instruction. She connected another infusion pump containing morphine with intravenous line. Nurse explained Mr. Evans the he could press the button placed on pump when he felt pain and specific amount of drug would get delivered to him.

Mr. Evans was explained about visual analogue scale (VAS) which will help understanding his pain status. He was told that he will be asked to rate his pain every time before giving any pain killer and one hour then after. He was continued on other NSAID group pain killer, diclofenac Sodium and prescribed oxycodone as need for pain control with a dose 30 minutes before physiotherapy. All nursing students are taught to assess the pain felt by patients by looking at patients’ facial expression and measuring pulse and blood pressure. Rising in blood pressure and pulse, facial grimace and rigidity of part of body indicates increasing level of pain.
Nurse started intravenous infusion of dextrose saline through peripheral vein and set the timing of automatic blood pressure measurement machine. She assessed Mr. Evan’s surgical site for fresh bleeding, made a note of urine out put and drain collection.
Nurse assessed circulation distal to operative site by looking at colour of skin and feeling character of pulses. She also completed a brief neurological examination by testing sensation in lower limb as formation of haematoma at epidural space may compress the spinal cord if patient is receiving anticoagulation. Mr. Evans was told not to move his right leg until purposeful ambulation planned. His right leg was splinted to keep it straight, which would be removed after 2 days.

    Total knee replacement is very painful in first 12 to 24 hours (Edge 2004) and post operative pain management is an important aspect of care for speedy recovery (Strong 2002).To control post operative pain, Mr. Evans was managed with epidural infusion of ropivacaine, Patient controlled analgesia with morphine, continued use of NSAID and oxycodone as required. Miss John noticed that with synergistic use of different technique, he maintained his VAS in the range of 2 to 3 in the recovery room where he stayed for four hours and shifted to ward. She was also aware of the fact that different institutions or departments have different set criteria for post operative pain management. (Cronn 2004)Use of epidural catheter for infusing various medication is widely accepted as it is considered effective way of controlling severe pain after total knee replacement().Study also shows that patients tolerate epidural anaesthesia after total knee replacement very well.( Smith 1999) )

To conduct epidural anaesthesia, anaesthetist put a small bore catheter in patients’ back with the help of a specially designed needle in a space around spinal cord called epidural space and secured over patient’s back with the end of it tapped over shoulder. Anaesthetist would give medication through catheter which will induce anaesthesia and make surgery painless. These drugs are called local anaesthetic which acts on spinal nerves emerging from spinal cord and block the conduction of nerve impulses passing through nerve fibers. It acts on sensory and motor nerves both, so apart from blocking all modalities of sensation, it also causes muscle weakness. Local anaesthetic agents keep patients pain free for certain period of time which is related to dose of drugs.

Epidural technique has got advantages over general anaesthesia technique. It helps reducing blood loss during surgery making surgical field cleaner and decreasing necessity of blood during surgery. Epidural anaesthesia technique can be extended further to achieve good postoperative pain relief as total knee replacement surgery is very painful for first 12 hours post operatively. This technique helps reducing incidence of deep pain thrombosis, which is a major concern after orthopaedic surgery as it causes dilatation of blood vessels and allowing early ambulation. It also allows patients to remain mobile while feeling pain free by using local anaesthetic agents in lower concentration.

Local anaesthetic agents can be given intermittently through epidural route to achieve effective pain control. (Fisher 2004)Study indicated that adding narcotic analgesic to local anaesthetic given by epidural route reduced the requirement of other narcotic analgesic given through PCA(Pollard 2004 ).It also contributed in reducing the side effects of morphine.( Main 2002)Changing epidural injection of drugs in to patient controlled manner has also proved its efficacy.(Wildsmith 2003 )
Patients were managed effectively with the use of patient control analgesia through intravenous route in addition to use of local anaesthetic epidurally.( )Study revealed that on asking nurses and patients to report about patients’ pain, nurses’ estimation was lower about intensity of pain of patients compared to patients-‘own perception(Hard 1996 ).  

Epidural catheter are removed on after two days of its insertion and PCA can be continued for 48 hours post operatively, to be substituted by oral medication for pain control during further course of rehabilitation. Non-steroidal anti inflammatory drugs (NSAID) and opiates form the major group used in recovery after total knee replacement.
    NSAID act by inhibiting cox-1 enzymes, prohibit prostaglandin synthesis, which is a responsible chemical for pain conduction at spinal cord level. NSAID are given with epidural anesthesia and PCA in post operative period of knee replacement surgery and continued further in rehabilitation. Although they are safe to use, a caution on gastrointestinal, renal and haematological side effects is required (Healy 2003).
Opiates are another group of drugs, acts on opiates receptors, located in central nervous system and affect perception of pain as pain is not a diseased but a noxious stimuli (Carter 1998)
Opiates can cause nausea, vomiting, constipation, respiratory depression and impair psychomotor functions. Addiction and tolerance to opiates after long term use are also matter of concern for this group of drug.

Apart from the types of techniques used for pain management for Mr. Evans, various methods had been tried with good success rate also. Nerve blocks like continuous femoral  nerve block in which a small bore catheter is passed inside the sheath of femoral nerve and infusion of ropivacaine given through catheter ( Jankovic 2004) .In continuous sciatic nerve block also with the help of catheter local anesthetic drug ropivacaine is infused, but unlike femoral nerve block it takes more time to establish its effect and also requires more volume of drug to block the nerve(Holdcroft 2003 ).Other nerve blocks like obturator nerve block, lumber plexus block and fascia iliaca block are used as an adjunct to femoral or sciatic nerve blocks. Combine use of more than one nerve block proved more effective than single nerve block. Intrathecal morphine had also been tried to reduce the side effects of oral and intravenous morphine. (Stein 1999)These methods are not as much effective as epidural technique. (Melzac 2002)

Other measures to relive pain are transcutenous electrical nerve stimulator (TENS) and acupuncture as they stimulate release of endorphins from body which acts as a pain relieving substances. In case of TENS, electrode pads are placed over painful site and mild current is passed through electrodes(Davi2000 ).Acupuncture is a Chinese technique, where small fine needles are placed at specified points on the body and mild tolerable current is passed from that needle(Vickers 1999 ).TENS and acupuncture both acts by releasing endorphins from the body. Endorphins are considered endogenous opiates help in reducing intensity of pain. Exercise is also believed to help in pain control also by releasing   endorphin. Ketorolac patch applied directly to painful site has also been tried to relieve pain.(Holdcraft 2003 )Ice packs applied on painful part of body also acts as a pain reliever.(Dougherty 2004 )

Mr. Evans was discharged home five days after surgery after meeting discharge criteria. He was advised not to drink while taking pain killers and contact doctor if feeling any of the following like pain increasing in intensity, temperature rising above 101 degree, swelling of knee increasing and not relieved by rest or elevation, noticing any bleeding, pain in calf or any injury to knee.  

Mr. Evans was managed with the combination of epidural anaesthetic technique, patient controlled analgesia and oral NSAID medications. Team work with multidisciplinary approach brought satisfactory pain control to Mr. Evans as indicated by Visual analogue scale. Effective postoperative pain management helped him getting discharged on time with out complications. Approach to pain can be variable from patient to patient as physiological condition of human body differs from one to another. Medicinal science has progressed  from the days of guillotine done without pain to the days of distinct concepts of  pain management where pain management is not just limited to perioperative region but expanding it’s horizons to cover pain management in Intensive care unit and emergency medicine also.


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