Does a Multimodal Analgesia Approach Help Reduce Postoperative Pain - Literature review Example

In Adult Patients Undergoing Orthopaedic Surgery, Dose A Multimodal Analgesia Approach Help Reduce Postoperative Pain, Side Effects And Opioid Dependence?” Name: Unit: Course: Professor’s name: Submission Date: Background and aims According to Hebl, Dilger, Byer, Kopp…….& Horlocker, (2008) in hospital wards, pain is rampant and deters patients’ treatment and recovery more so among the orthopaedic patients. Inadequate analgesia provision is likely to deter early rehabilitation and physical therapy initiation and support fundamental for maintaining motion on joint range and assuring hospital dismissal. Thus, adequate, and suitable analgesic among these patients has been a clinical issue for both pre and postoperative period. Therefore, following the present-day challenges on postoperative pain management among the orthopaedic patients and increasing health burden on the same this literature review seeks to establish by answering the question “in adult patients undergoing orthopaedic surgery, dose a multimodal analgesia approach help reduce postoperative pain, side effects and opioid dependence?” whether a better postoperative pain management and less side effects outcome among orthopaedic patients can be realized with limited use of narcotics. Vendittoli, Makinen, Drolet, Lavigne, Fallaha, Guertin & Varin (2006) this is imperative because although, parenteral narcotics are dominantly used in postoperative pain control measures it has well known side-effects such as pruritus, respiratory depression, sedation, dizziness, urinary retention, constipation, confusion, vomiting and nausea. Research strategies To address this question, PICOT tool was used see table 1. Table 1: PICOT table Population Intervention Outcome Adult patients undergoing orthopaedic surgery a multimodal analgesia regimen pain and side effects reduction Further, the author used various keywords to navigate search as shown in table 2 below. Table 2: Search keywords Question Concepts McSH Subject Heading Keywords Orthopaedic surgery Arthroplasty, total knee replacement OR hip surgery, knee OR ankle replacement, arthroplasty OR elbow replacement, orthopaedics OR surgical, Or arthroplasty OR operation Or orthopaedic surgical AND Multimodal Analgesia Analgesia, postoperative pain analgesia OR postoperative analgesia OR analgesia OR combined modality therapy OR patient controlled analgesia OR analgesia, multimodal analgesia approach OR multimodal analgesia OR opioid OR anaesthetics OR Analgesic OR morphine AND Pain Patient satisfaction OR postoperative pain OR Pain management postoperative care Pain and rehabilitation OR pain side effects OR postoperative pain aetiology OR control pain ; The search did use various keywords, and their synonyms surrounding the case study and clinical terms that could lead the search in answering the question of interest in this literature review. The search did use AND/ OR to narrow down the subjects and help obtain SMART peer reviewed publications. The literature material were primarily collected from clinically approved databases for authentications of the results obtained and analysed here in. Multimodal analgesia regimen efficacy in reduction of postoperative pain, side effects and opioid dependence discussion Lee, Lee & Choy, (2013) to understand the efficacy of multimodal analgesic, a randomized prospective study was carried out. The study was done among 61 patients undergoing surgical process of the upper extremity. The subjects were randomly divided into two perioperative analgesic group; a patient-controlled analgesia (PCA) and a multimodal analgesia group pain control. The research did investigate patient’s satisfaction, opioid-related complication rate and additional pain rescue dissemination to the patients. The study did show that both groups had no significant difference in regards to exercise and the resting pain scores, postoperative day 1 & 2 additional pain rescue and rehabilitation protocol achieved. Nevertheless, following PCA removal, among the PCA group additional pain rescue use was significantly increased. A significant difference was recorded in regards to the opioid-related complications incidences during the day of operation and post-operative day (POD) 1. Compared to the PCA group, the multimodal analgesia group at discharge was found to be more satisfied. The study did conclude that for upper extremity surgery, perioperative pain management via multimodal analgesia is the preferable alternative method to realize positive results. Dorr, Raya, Long, Boutary & Sirianni, (2008) argues that the gold standard of managing pain following total knee arthroplasty (TKA) is parenteral narcotics. The authors did a study to establish whether alternative use of oral multimodal pain medication protocol would be preferable in minimizing complication that comes with parenteral narcotics application and control pain better. In their study, either continuous femoral infusion or continuous epidural infusion was used to strengthen postoperative oral analgesia using ropivacaine only. TKA was carried on 70 patients using postoperative analgesia, pericapsular analgesic injection, epidural anesthesia and preemptive oral analgesia with absence of parenteral opioids protocol. The study did find that on a daily basis on average VAS score was below 4/10, nausea was present among 15 patients (21%), emesis was recorded in 1(1.4%) patient and no severe complication recorded. Therefore, pain management following total knee arthroplasty is feasible via non-parenteral opioids protocols. The study however, lacked control group for excellent authentication outcome. Vendittoli et al., et al., (2006) for instance supports nausea presentation among the trial cases on multimodal analgesia. The authors noted that nausea occurred among the trial cases and took shorter lengthy to clear unlike the controls (2.6 ± 3.9 hours versus 7.1 hours ± 12.2 hours, p=.011) although morphine was used in both cases. Fu, Xiao, Zhu, Wu, Li, Wu, and Qian, (2010) randomly assigned 100 osteoarthritis patients prepared to undergo unilateral total knee arthroplasty to either a multimodal analgesia protocol or control group. The trial group received large doses intra-articular injection of betamethasone, adrenaline, ropivacaine, and morphine during surgery, tramadol and oral celecoxib pre- and post-operative process. Patient-controlled analgesia was administered to all patients in the first 48-postoperative hours. Among the trial group, morphine consumption was lower during 48-postoperative hours compared to the controls. Pain at rest VAS scores were lower from 6-7 hours at rest following surgery with more decreased noted after 24 hours-7days postoperative among the trials than the controls. Within 1-15 days, trial cases achieved active straight leg raise, reasonable knee movement and 900 active knee flexion with more days observed among the controls. Similar health postoperative complications deep vein thrombosis, urinary retention, respiratory depression, rash, heart rate, blood pressure, infection and wound healing were noted on the two groups. Vomiting and nausea frequency limited among the controls which contradicts the Dorr et al., (2008) findings that nausea was present among 15 of 70 patients (21%) on multimodal analgesia regimen cases only. Lamplot, Wagner & Manning, (2014) did a prospective randomized controlled study in 36 patients undergoing TKA to help understand multimodal analgesic regimen effects in respect to satisfaction, adverse effects, function and on postoperative pain in comparison to patient-controlled analgesia (PCA). The patients were randomly grouped to receive either hydromorphone PCA (Control) or multimodal analgesics (ketorolac, tramadol, oxycodone; narcotics as required) and periarticular injection prior to wound closure (15mg ketorolac, 10mg MSO4, 30cc 0.5% bupivacaine). The study did observe that multimodal group recorded decreased VAS scores, high chances of starting physical therapy milestones early, higher satisfaction scores, lower narcotic usage and fewer adverse effects. The research did draw a conclusion that multimodal management regimen enhances early recovery, increases satisfaction, improves pain scores, and decreases narcotic usage. Rafiq, Steinbruchel, Wanscher, Andersen, Navne, Lileoer &Olsen (2014) did a research to evaluate whether a multimodal regimen of opiate sparing protocol including paracetamol, ibuprofen, gabapentin and dexamethasone, realized better analgesic effects, was more safe than traditional paracetamol and traditional morphine regimen and had less side effects after cardiac surgery. The prospective randomized controlled open label trial enrolled 180 patients undergoing cardiac surgery via median sternotomy from 2007-March to 2009-August and 151 patients made it to the analysis stage. There was pronounced lower pain scores on average among the multimodal group since the surgery day to post-operative day (POD) 3. No extensive vomiting and nausea mong the multimodal group, but the controls recorded 13 patients, p< 0.001. No significant increase in creatinine levels among the multimodal subjects, with 33.0±53.4 versus 19.9±48.5, p=0.133. Further, did note that the subjects had less major-hospital episodes of death rates, gastrointestinal bleeding, dialysis, stroke and myocardial infarction. With multimodal regimen no safety measures observed during the study. The findings, questions Fu, et al (2010) on their conclusion that controls on intra-articular and oral placebo, with all cases receiving morphine; although trials had large doses of morphine, the outcome had limited side effects reduction. Hebl, et al (2008) did review application of Mayo Clinic Total Joint Regional anaesthesia (TJRA) protocol which is perioperative, pre-emptive, multimodal regimen effect with emphasizes on nerve block among 100 patients undergoing TKA and total hip arthroplasty (THA). The stay in the hospital was the primary outcome, while discharge eligibility, joint range of motion, and ambulation formed the secondary variables. The review research showed that TJRA patients stays in hospital for shorter period unlike the controls (3.8 days vs 5.0 days; p Read More