• Current Issue
• ACP Hospitalist Weekly
• Supplements
• Blog
• Archives
  • By Topic
• Career Connection
• Subscribe to RSS Feeds

Managing pain in orthopedic patients takes awareness, finesse

By Diane Shannon, MD

From the May ACP Hospitalist, copyright © 2008 by the American College of Physicians

Sidebars: Tips for the safe management of pain in orthopedic patients How management models vary

A frail 92-year-old woman falls in the dining hall of her assisted living facility, sustaining an intertrochanteric fracture of the right hip. On hospital admission, routine lab tests, including complete blood count, electrolytes, blood urea nitrogen and creatinine, are normal. She undergoes hip replacement surgery under spinal anesthesia without complications and is alert and oriented postoperatively.

A patient-controlled analgesia morphine pump is initiated for pain control, set at the recommended dose for an opioid-naïve patient (2 milligrams every 10 minutes with a four-hour lockout rate of 24 milligrams). The patient is too drowsy to take her oral medications the next morning. What’s the likely cause of the woman’s sedation?

This case illustrates some of the complexities often present in pain management for orthopedic patients. The patient had low muscle mass, so her serum creatinine concentration remained within the normal range despite a significant reduction in her glomerular filtration rate. Reduced kidney function can lead to accumulation of opioid metabolites, which can result in associated side effects, such as respiratory depression and sedation. For appropriate pain management, this patient needed a lower dosage of morphine.

Top

Two types of patients

Patients who need pain management after orthopedic surgery usually fall into two very distinct groups. Those admitted for surgical repair of a fracture are often elderly and have several comorbid conditions—such as diabetes, hypertension or chronic renal insufficiency—that may complicate their care. They’re usually admitted under more urgent circumstances and may not have had the benefit of preoperative education or a comprehensive medical evaluation. Patients admitted for elective joint replacement, in contrast, tend to be younger, sometimes with fewer comorbid conditions, and usually have been evaluated and educated preoperatively.

Hospitalists should always be on the lookout for patients whose opioid requirement is higher or lower than the standard recommended dose, according to experts. Elderly patients with low body mass who have never taken opioids may require a much lower dose than younger, heavier patients who have used opioids in the past. In contrast, patients with a history of long-term opioid use before surgery are at risk for opioid withdrawal or insufficient pain management postoperatively.

Because pain management in orthopedic patients often involves intricate decisions, hospitalists are ideally situated to improve clinical care in this group, experts said.

“The hospitalists’ role is critical when the ‘art’ of applying evidence-based pain management is required.” —Vijay Rajput, FACP

“The hospitalists’ role is critical when the ‘art’ of applying evidence-based pain management is required,” said Vijay Rajput, FACP, a hospitalist and associate professor of medicine at UMDNJ-Robert Wood Johnson Medical School in Camden, N.J. “For elective surgery, hospitalists play an important role in identifying preoperatively the patients at greater risk for complications with analgesics.”

Hospitalists should be aware of the following when managing pain in postoperative patients, experts said.

• Opioids’ more common side effects include nausea and vomiting, constipation, ileus, confusion, delirium, and urinary retention in patients with benign prostatic hyperplasia.
• Careful monitoring is needed in patients at risk for opioid-associated respiratory depression due to obesity or sleep apnea, or to the extended half-life of active metabolites in the setting of renal dysfunction.
• Patients who develop delirium postoperatively should be evaluated for alcohol withdrawal.
• In patients with mild dementia, uncontrolled pain can present as agitation, confusion or psychosis.

Top

What’s new

Over the past five years, an array of new agents and new delivery methods has become available. Extended-release opioids using liposomal technology are now being used to deliver 48-hour pain relief via epidural injection without the need for an indwelling catheter. Other delivery options, such as a needle-free credit-card-sized iontophoretic transdermal system, are currently being studied.

A relatively recent trend in the management of postoperative pain is the focus on the use of a combination of analgesic agents rather than reliance on opioids alone. “Over the past five years, we’ve developed a greater understanding of the need for multimodal therapy,” said Craig J. Della Valle, MD, associate professor of orthopaedic surgery at Rush University Medical Center in Chicago. A primary goal of multimodal pain management, he said, is the use of a variety of drug classes to reduce the opioid requirement, thus minimizing the risk of opioid-associated side effects. An example of multimodal therapy is the combined use of spinal or epidural anesthesia, a peripheral nerve block, local injection at the operative site, a COX-2 inhibitor, pregabalin and other agents.

Many pain management strategies also include preventive or “preemptive” analgesia, which is the administration of analgesic agents prior to and during surgery to prevent postoperative pain. Agents such as COX-2 inhibitors, ketamine, pregabalin and acetaminophen are currently used for preemptive analgesia.

Preoperative patient education also is an important tool for pain management, according to Kulsum K. Casey, ACP Member, a hospitalist in the division of hospital medicine at the Mayo Clinic in Rochester, Minn. “Research has shown that educating patients about what to expect after their particular surgical procedure can reduce anxiety and their impression of pain postoperatively,” he said.

One of the most important reasons hospitalists are able to facilitate appropriate pain management is the amount of face time they spend with the patient, said Javad Parvizi, MD, associate professor of orthopedic surgery and director of clinical research at the Rothman Institute at Thomas Jefferson University Hospital in Philadelphia.

“Hospitalists often see the patient more frequently than the anesthesiologist or surgeon,” he said. “By helping foster communication among members of the team and with the patient, it’s possible to achieve satisfactory analgesic control.”

Dr. Shannon is a freelance writer in Brookline, Mass.

Top

---

.

Tips for the safe management of pain in orthopedic patients

Eugene R. Viscusi, MD, director of regional anesthesia and acute pain management in the department of anesthesiology at Thomas Jefferson University in Philadelphia, recommends these safety tips for hospitalists managing pain in orthopedic patients.

Ask the patient to describe the type of pain he or she is experiencing. Pain that is relatively unrelated to movement of the affected joint may represent underlying muscle spasm. Treating muscle spasm with relaxants—rather than increasing the analgesic dose—will more effectively treat the pain and will minimize the dose of analgesics and the associated risk of side effects.

Consider preventive treatment. There is emerging evidence that oral analgesics such as the COX-2 selective inhibitors, acetaminophen and some agents usually used to treat neuropathic pain may have a profound effect on postoperative pain when given before surgery.

Use oral analgesics. Add oral nonopioid analgesics as soon as patients are able to safely swallow postoperatively. Switch from topical or infused opioids to oral agents when patients can fully tolerate oral medications and the oral agents are able to meet the patient’s pain requirements. Plan to overlap use of patient-controlled analgesia (PCA) and oral agents to avoid an unnecessary gap in pain control. According to Dr. Viscusi, knee replacement patients are often able to make this switch on post-op day two. Patients undergoing hip replacement often switch to oral opioids on post-op day one.

Set the baseline infusion of PCA pumps at zero. Use of adjuvant analgesic along with PCA will provide effective pain control without a baseline or basal infusion of opioids and will reduce the risk of respiratory depression. According to Dr. Viscusi, this approach is effective in all patients except those profoundly tolerant to opioids due to long-term preoperative use.

Calculate and track the patient’s total daily dose of acetaminophen. Postoperative patients often receive the drug as a single agent for fever or other symptoms and in combination with opioids for pain control. Unless the total dose is tracked, a patient could exceed the safe limit of 4 grams a day.

Be aware of opioid metabolites. Opioid agents produce metabolites that can have extended half-lives, especially in patients with renal insufficiency. These metabolites generally provide proportionally less analgesia and greater risk of side effects than the parent compound. Amp up the use of nonopioid analgesics to provide pain control in these patients to reduce the risk of respiratory depression and other opioid-related complications.

Top

---

.

How management models vary

The way you handle orthopedic patients will probably differ by patient diagnosis and treatment requirements, according to reports from different programs. Hospitalists at UMDNJ-Robert Wood Johnson Medical School in Camden, N.J., often manage the care of patients admitted for treatment of joint fractures, focusing on the preoperative medical evaluation, cardiac risk stratification and prophylaxis for deep venous thrombosis (DVT), said Vijay Rajput, FACP, a hospitalist and associate professor of medicine. This group of patients is admitted to the hospitalists’ service, and the orthopedic consult service manages other aspects of their care. In contrast, the hospitalists at UMDNJ-Robert Wood Johnson serve as consultants when patients are admitted for elective joint replacement, working with the surgeons to address DVT prophylaxis, pain management and other issues.

At Strong Memorial Hospital in Rochester, N.Y., the division of labor is similar, but the emergency department initiates an automatic consult to the hospitalist service for all patients with chronic medical problems who are admitted to the orthopedic service for surgical treatment of a fracture, said Andrew Rudmann, ACP Member, associate professor and chief of the hospital medicine division. "When patients are medically unstable or have numerous medical comorbidities, they are admitted to the hospitalist service with orthopedics following as consultants until timing is optimal for the fracture repair," Dr. Rudmann said. As at UMDNJ-Robert Wood Johnson, patients hospitalized for elective joint replacement are admitted to the orthopedic service with a hospitalist consultation.

At Mercy Medical Center in Springfield, Mass., the hip fracture service is run by hospitalists, said Winthrop F. Whitcomb, ACP Member, a hospitalist and co-founder of the Society of Hospital Medicine. “Only patients with uncomplicated hip fractures that are verified by a radiologist’s reading and have no other orthopedic complications can be admitted to the service. Orthopedic surgeons are available for phone consultation if we have any management questions, and they evaluate any patients admitted at night by the next morning,” he said. Primary management of hip fracture patients may become more common for hospitalists, Dr. Whitcomb predicted: As a hospitalist consultant, over the past few years he’s seen the number of hospitalist-run hip fracture services grow.

Top

Hospitalist Archives
Quick Links

ACP Hospitalist Weekly

From the July 28, 2010 edition

• After general surgery, sepsis and septic shock far more common than PE, MI
• Opt-out tests in ED detect slightly more patients with HIV

View issue

Cartoon Caption Contest

ACP staff has selected three finalists for the latest contest and is now asking readers to vote for their favorite caption to determine the winner.

Is Your Practice Ready For Meaningful Use?

MKSAP for Students 4 and Internal Medicine Essentials for Clerkship Students 2 Package

© 2010 ACP Hospitalist and American College of Physicians

ACP Hospitalist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated