Yu Stephen, Dundon John, Solovyova Olga, Bosco Joseph, Iorio Richard
NYU Langone Medical Center, Hospital for Joint Diseases, New York, NY, USA.
Clin Orthop Relat Res. 2018 Jan;476(1):101-109. doi: 10.1007/s11999.0000000000000018.
TKA pain management protocols vary widely with no current consensus on a standardized pain management regimen. Multimodal TKA pain management protocols aim to address pain control, facilitate functional recovery, and maintain patient satisfaction.
QUESTIONS/PURPOSES: (1) Did changes to our pain management protocol, specifically adding liposomal bupivacaine, eliminating patient-controlled analgesia (PCA), and discontinuing femoral nerve blocks (FNBs), affect narcotic consumption after TKA? (2) Did these changes to our pain management protocols affect patient-reported pain scores? (3) Does the use of an immediate postoperative PCA affect rapid rehabilitation and functional recovery? (4) How did changes to our pain management regimen affect discharge disposition and pain-related Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores?
We retrospectively analyzed an institutional arthroplasty database between September 2013 and September 2015 containing 1808 patients who underwent primary TKA. Departmental pain management protocols were compared in 6-month periods as the protocol changed. All patients received a multimodal pain management protocol including preoperative oral medications, spinal or general anesthesia, a short-acting intraoperative pericapsular injection, and continued postoperative oral narcotics for breakthrough pain. From September 2013 to April 2014, all patients received an intraoperative FNB and a PCA for the first 24 hours postoperatively (Cohort 1). From May 2014 to October 2014, a periarticular injection of liposomal bupivacaine was added to the protocol and FNBs were discontinued (Cohort 2). After April 2015, PCA was eliminated (Cohort 3). No other major changes were made to the TKA pain management pathways. Narcotic use, pain scores on 8-hour intervals, physical therapy milestones, and discharge disposition were compared.
Total narcotic use was the least in Cohort 3 (Cohort 3: 66 ± 54 morphine milligram equivalents versus Cohort 2: 82 ± 72 versus Cohort 1: 96 ± 62; p < 0.001). There was an increase in pain score immediately after surgery in Cohort 3 (4.0 ± 3.5 versus 1.2 ± 2.2 versus 1.2 ± 2.5, post hoc analysis of Cohort 2 versus 3: mean difference 2.6, 95% confidence interval [CI] 2.2-3.0; p < 0.001); however, it was not different for the remainder of the hospital stay. Patients who did not receive PCA reached functional milestones for both gait and stairs faster by postoperative day 1 (47% [328 of 698] versus 30% [158 of 527] versus 16% [93 of 583], p < 0.001; Cohort 3 versus 2: odds ratio 2.1, 95% CI 1.6-2.6; p < 0.001). Discharge to home occurred more frequently (84% [583 of 698] versus 78% [410 of 527] versus 72% [421 of 583], p = 0.010) in Cohort 3. There were no differences in pain-related HCAHPS scores across all cohorts.
Discontinuing PCAs and FNBs from our multimodal TKA pain management protocols and adding liposomal bupivacaine resulted in fewer narcotics consumed with no difference in pain control and faster functional recovery while maintaining high HCAHPS scores relating to pain.
Level III, therapeutic study.
全膝关节置换术（TKA）的疼痛管理方案差异很大，目前对于标准化疼痛管理方案尚无共识。多模式TKA疼痛管理方案旨在控制疼痛、促进功能恢复并维持患者满意度。
问题/目的：（1）我们的疼痛管理方案的改变，特别是添加脂质体布比卡因、取消患者自控镇痛（PCA）和停用股神经阻滞（FNB），是否会影响TKA术后的麻醉药物消耗量？（2）这些疼痛管理方案的改变是否会影响患者报告的疼痛评分？（3）术后立即使用PCA是否会影响快速康复和功能恢复？（4）我们的疼痛管理方案的改变如何影响出院处置以及与疼痛相关的医疗服务提供者和系统医院消费者评估（HCAHPS）评分？
我们回顾性分析了2013年9月至2015年9月期间的机构关节置换术数据库，其中包含1808例行初次TKA的患者。随着方案的改变，在6个月的时间段内对部门疼痛管理方案进行比较。所有患者均接受多模式疼痛管理方案，包括术前口服药物、脊髓或全身麻醉、术中短效关节周围注射以及术后持续口服麻醉药物以缓解突破性疼痛。2013年9月至2014年4月，所有患者均接受术中FNB，并在术后头24小时使用PCA（队列1）。2014年5月至2014年10月，方案中添加了关节周围注射脂质体布比卡因并停用FNB（队列2）。2015年4月之后，取消了PCA（队列3）。TKA疼痛管理途径没有其他重大改变。比较了麻醉药物使用情况、每8小时一次的疼痛评分、物理治疗里程碑以及出院处置情况。
队列3中的总麻醉药物使用量最少（队列3：66±54吗啡毫克当量，队列2：82±72，队列1：96±62；p<0.001）。队列3术后立即的疼痛评分有所增加（4.0±3.5，队列2为1.2±2.2，队列1为1.2±2.5，队列2与队列3的事后分析：平均差异2.6，95%置信区间[CI]2.2 - 3.0；p<0.001）；然而，在住院的其余时间并无差异。未接受PCA的患者在术后第1天更快达到步态和上下楼梯的功能里程碑（47%[698例中的328例]，队列2为30%[527例中的158例]，队列1为16%[583例中的93例]，p<0.001；队列3与队列2比较：优势比2.1，95%CI 1.6 - 2.6；p<0.001）。队列3中更频繁地出院回家（84%[698例中的583例]，队列2为78%[527例中的410例]，队列1为72%[583例中的421例]，p = 0.010）。所有队列中与疼痛相关的HCAHPS评分没有差异。
从我们的多模式TKA疼痛管理方案中停用PCA和FNB并添加脂质体布比卡因，导致麻醉药物消耗量减少，疼痛控制无差异，功能恢复更快，同时保持了与疼痛相关的高HCAHPS评分。
III级，治疗性研究。
