Pain

 

Multimodal Post-op Pain Management

decadron 6-8 mg iv prior to case
ketolac 30mg at end of case, then 30mg Q6 x 3 doses (consider intranasal toradol)
celebrex or mobic
intervenous tylenol
Prevent post op nasuea: zofran, scopoloamine patch
schedule hydrocondone or oxycodoone
Dilaudid IV rescue

 Exparel injection

  • 20cc Exparel (266 miligrams)
  • 25cc 0.5% Marcaine (plain)
  • 0.5mg 1/1000 epinephrine
  • 30mg toradol
  • mix in 60 cc syringe with saline to total 60cc
  • inject using 20 or 21 gauge spinal needle
  • Do not use toradol in renal impaired patients
  • Current prospective, randomized controlled trials fail to support the routine use of liposomal bupivacaine compared with other local injectable analgesics, particularly in TKA. (Abildgaard AT, JBJS Reviews: July 2019 - Volume 7 - Issue 7 - p e8 doi: 10.2106/JBJS.RVW.18.00192)

Ketorolac

  • Pre-op: 15-30mg IV
  • Post-op: 15-30mg Q6hrs for 7 doses
  • Contraindications: renal insufficiency

Ibuprofen

  • Pre-op: 800mg PO
  • Post-op:  800mg PO Q6hrs
  • Contraindications: GERD/PUD

Celecoxib

  • Pre-op: 400mg PO
  • Post-op:  200mg PO Q12hrs
  • Contraindications: sulfa allergy

Gabapentin

  • Gabapentin does not reduce morphine consumption or opiod-related side affects following TKA.  (Paul JE, JBJS 2013;95:2060)
  • Pre-op: 300mg PO
  • Post-op:  300mg PO Q12hrs
  • Contraindications: renal insufficiency

Pregabalin

  • Pre-op: 75mg PO
  • Post-op:  75mg PO Q12hrs
  • Perioperative use of pregabalin may decrease post-operative opioid consumption (Burke SM, Shorten GD. Perioperative pregabalin improves pain and functional outcomes 3 months after lumbar discectomy. Anesth Analg. 2010 Apr 1;110(4):1180-5)
  • Contraindications:

Acetaminophen

  • Pre-op: 1000mg IV
  • Post-op:  650mg IV Qhrs
  • Contraindications: liver disease

References

  1. Parvizi J, Orthopedics 2013;36:7-14