Dealing with Pain Using a “Fast-Track” (Multimodal) Protocol: The Experience from the United States

Drug

Preemptive dose

Postoperative dose

Route of administration

Acetaminophen

975 mg

650 mg q6h

IV/PO

Paracetamol

2 g

2 g q4h

IV/PO

Celecoxib

400 mg

200 mg q12h

Naproxen

500 mg

500 mg q12h

Ketorolac

12–30 mg

15–30 mg q6h

IV/PO

Ibuprofen

600 mg

600 mg q6h

Pregabalin

75 mg

75 mg q12h

Gabapentin

300 mg

300 mg q24h

Tramadol

–

50 mg q6h

Oxycodone

–

10 mg q6h

Breakthrough pain is managed with intravenous ketorolac 30 mg (or ibuprofen 600 mg), oral tramadol 50 mg, or oral oxycodone 10 mg. PCA is used only if the patient is not responding to any of the above-mentioned measures. Once PCA is used, fentanyl is the preferred drug and Dilaudid is used as a second line agent.

16.5 Overview

Pain management has significantly contributed to the overall satisfaction of patients undergoing TJA. The main principle of modern pain management in TJA patients is pain prevention rather than pain treatment. It is widely accepted that reducing opioid consumption and their side effects is crucial for successful “fast-track rehabilitation” after TJA. The reduction of opioid consumption is achieved by implementation of the multimodal pain management principles. Preemptive analgesia has a major role in TJA pain management by lowering the initial inflammatory response related to the surgery. The current literature strongly supports the use of NSAIDs, acetaminophen, and gabapentinoids prior to the incision. There is substantial evidence showing that spinal and/or epidural anesthesia is superior to general anesthesia in terms of venous opioid-induced adverse events, thromboembolism, intraoperative blood loss, respiratory complications, and mortality. Local analgesia, either by infiltration of the surrounding tissue or by intraarticular continuous administration, has been shown to reduce opioid consumption and their related side effects, and its usage is rapidly expanding during the recent years. The cumulating effects of other treatment options are not as well studied as the former medications in the setting of multimodal pain management. There is still conflicting and insufficient data regarding the use of tramadol, NMDA receptor antagonists, cryotherapy, and the preferred nerve blockade, and substantial research is warranted before a widely accepted protocol could be proposed.

Key Points

Modern pain management in TJA patients is pain prevention rather than pain treatment.
Reducing opioid consumption and their side effects with multimodal pain management is crucial for successful “fast-track rehabilitation” after TJA.
Spinal and/or epidural anesthesia is preferred rather than general anesthesia.
Local analgesia, either by infiltration of the surrounding tissue or by intra-articular continuous administration, has been shown to reduce opioid consumption.
The use of tramadol, NMDA receptor antagonists, cryotherapy, and the preferred nerve blockade is still under scrutiny in order to define their correct application.

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