Management Of Postoperative Pain In A Patient Undergoing Total Knee Replacement Surgery

Background

The patient is in the emergency ward and is experiencing pain of intensity 7/10 in her left knee as she had underwent a total knee replacement surgery under general anesthesia.

The patient had a past history of osteoarthritis in both the knees, having a limited range of movements and the pain on weight bearing in the left knee (Wylde et al., 2015). After prolonged suffering from osteoarthritis, the patient might have opted for osteoarthritis, as it provides the greatest improvement in the quality of life of the patient with functional impairment. She also had a history of Type 2 diabetes, hypertension, and fatty liver and diabetic neuropathy in both the feet with mild neuropathic pain, without any neurologic deficit (Wylde et al., 2015).

Mar is fully alert and her GCs is 15/15, her surgical wound is dry and her PCS has not been  assessed in the past hours. She had been suffering from pain at an intensity of 7/10 in her left knee. Most of the patients who have undergone a hip replacement surgery experience chronic pain after total knee replacement arthoplasty. Mary had been feeling lightheaded and had less appetite for food. There is a 18 G IV catheter in the tight hand and 200 mL isotonic saline in the IV bag, running at 80 mL per hour and the PCA circuit is attached to the line. Her BP 60 minutes ago was 123/70, radial pulse was 55, RR20, SpO2 is 93 %, FiO2 0.21, T36.2, peripheral capillary refill 2 seconds. The current vital signs were- BP- 105/56, RR20, radial pulse 66 regular, SpO2 93%, FiO2 0.21, T36.4 tympanic. BGL11.5mmol/L, the peripheral capillary refill is 2 seconds and pale cool digits.

Knee pain after a total knee replacement might occur due to the loosening of the implant, infection, other palletofemoral problems or the alignment problems. Knee pain can also be caused due to pinched nerve in the lower back (Wylde et al., 2015). The common peritoneal nerve, the branch of sciatic nerve that courses from a knee over the top of the fibula bone , are affected after a total knee replacement (Uesugi et al., 2014). This nerve is susceptible to injury after the total knee replacement. It is evident from the case study that Mary is 85 years old and it is normal to feel fatigued after a big surgery. Lightheadedness can also be caused due t the prolonged intake of the medicines like metoprolol.

Assessment

The patient had past history of hypertension but acute hypotension can occur after a total knee arthoplasty (Zhang et al., 2015). It is clear that the BP of the patient had lowered suddenly within a span of 60 minutes. The anesthetic drugs used at the time of the surgery can affect the blood pressure. Again losing a large amount of blood at the time of the surgery can lead to hypovolemic shock leading to a drop in the blood pressure levels. The factors responsible for the increase in the post-operative hypotension is related to age, the pressure of the tourniquet and the type of surgery conducted. According to Zhang et al., (2015), the elderly patients cannot regulate the tension in the blood capillary bed after the surgery and the interstitial fluid cannot be transferred to the blood vessel timely causing hypotension. Initially, the radial pulse was low which became normal after 60 minutes. Again increased respiratory rate right after the surgery can be a sign of the advent of some major adverse events like the development of the sepsis (King,  Morton & Bevan, 2014)..

Again the normal blood glucose value is 5.6mmmol/L, hence 11.mmol/L is a quite high value.

According to the case scenario, the patient had lack of appetite and hence the food intake is too low. In such cases the patient might develop hypoglycemia and develop light headedness (Rajamäki et al., 2015). The capillary refill time for the patient is also increasing as per the standard value. A prolonged capillary refill time might indicate towards the development of the sepsis or shock and might also indicate towards decreased peripheral perfusion.

It can inferred from the symptoms, that sepsis might have occurred, which can be understood by the prolonged capillary refill time, the pale skin and the increased respiratory rate. The septic shock might also be caused due to infection or due to diabetes (Nielen et al., 2015).

• To increase her blood pressure level
• To increase her capillary refill time
• To increase her appetite to the food in order to prevent any chance of the occurrence of the hypotension.
• To alleviate pain within 2 hours.

One of the main strategy for the management of the post-operative pain is the administration of the preemptive analgesics. Mary should be encouraged to intake liquid food and high protein diet with roughage as this helps to maintain the nutritional and the fluid balance supporting tissue perfusion and provision of the nutrients necessary to prevent the chance of hypotension (Webb et al., 2014). Medicines for the diabetes should be commenced by the supervision of the surgeon. Comfort measures and diversional activities can be used to get relief from the pain. Application of ice packs can also be useful for alleviating pain to a milder extent. In order to prevent any chances of infection, it is necessary to maintain the patency of the drainage devices to reduce the risk of infection. Clean and aseptic techniques should be used while handling the drains.

Causes of Knee Pain after Total Knee Replacement Surgery

It is necessary to keep an eye on the blood glucose level as the level is high that might have caused a diabetic shock in the patient. Furthermore, the pain should also decrease after the administration of the analgesics. The oxygen saturation level should also be restored after the application of the oxygen therapy.

From this experience, I have understood that I could have assessed the PCA after the patient has gained his consciousness, as it is mentioned in the case study that the patient was feeling lightheaded , which can be due to the prolonged action of the anesthesia. Furthermore, I need to check about the contraindication of the analgesics before their application. Again, medications like Hypericum might have side effects like dizziness and tiredness.

1. The moments of deterioration and the clinical priorities that can be perceived from the case study are- The pain in the left knee, drastic decrease in the blood pressure level, the patient in feeling nauseated, the heart rate had increased, the oxygen saturation level in the patient had decreased along with a prolonged capillary refill time. The interventions has been justified by using the “Slippery slope” of patient deterioration.

Four important interventions that can be given to the patient are as follows-

• Acute pain- It is necessary to assess the pain noting down the intensity, duration and the location of the pain. The operated extremity has to be positioned properly. Comfort measure like frequent repositioning, frequent rubs and therapeutic touches can be provided. Narcotics and the analgesics and muscle relaxants can be given and it is necessary to monitor the PCA and the epidural transfusion.

Positioning of the extremity helps to reduce the muscular spasm and undue the tension on the newly implanted prosthetics. Provision of the comfort measures helps in reducing the muscle tension. Application of the analgesics helps in providing relief to the surgical pain. It is necessary to have a note that some NSAIDs might be contraindicated in the patient. It is necessary to perform a clinical review of the pain medications before the deterioration.

• Diabetes management- The patient should be encouraged for the food intake as prolonged fasting after the surgery might lead to higher insulin resistance. Early mobilization, minimization of the fasting period is the initial steps for the diabetes management (Akiboye & Rayman, 2017). After the patient had been provided with food antidiabetic medications can be given under the supervision of the doctor. It is also necessary to monitor the blood glucose level within few intervals of time (Akiboye & Rayman, 2017).
• Increasing the oxygen saturation level- Oxygen therapy can be commenced with in case of severe respiratory trouble, but some of the other methods include – Raising the head of the bed and positioning the patient in the semi-fowler position can helps in lung expansion and decreases the work of breathing (Broens et al., 2014).
• Management of the BP- standard monitoring of the arterial blood gases and the , the oxyhemoglobin saturation, the heart rhythm should be monitored. It is necessary to consider the blood pressure pulse, the central venous pressure and some of the other parameters for preventing the incidence of acute hypotension. Medications can be given or some of the post-operative exercises like active ankle and knee movement and the isometric contraction of the quadriceps femoris can help to prevent acute hypotension.

References

Akiboye, F., & Rayman, G. (2017). Management of Hyperglycemia and Diabetes in Orthopedic Surgery. Current diabetes reports, 17(2), 13.

Broens, S. J., He, X., Evley, R., Olofsen, E., Niesters, M., Mahajan, R. P., Dahan, A., … van Velzen, M. (2017). Frequent respiratory events in postoperative patients aged 60 years and above. Therapeutics and clinical risk management, 13, 1091-1098. doi:10.2147/TCRM.S135923

Egli, S., Pfister, M., Ludin, S. M., de la Vega, K. P., Busato, A., & Fischer, L. (2015). Long-term results of therapeutic local anesthesia (neural therapy) in 280 referred refractory chronic pain patients. BMC complementary and alternative medicine, 15(1), 200.

King, D., Morton, R., & Bevan, C. (2014). How to use capillary refill time. Archives of Disease in Childhood-Education and Practice, 99(3), 111-116.

Korean Knee Society (2012). Guidelines for the management of postoperative pain after total knee arthroplasty. Knee surgery & related research, 24(4), 201-7.

Nielen, J. T., Emans, P. J., Dagnelie, P. C., Boonen, A., Lalmohamed, A., de Boer, A., … & de Vries, F. (2016). Severity of Diabetes Mellitus and Total Hip or Knee Replacement: A Population-Based Case–Control Study. Medicine, 95(20).

Rajamäki, T. J., Jämsen, E., Puolakka, P. A., Nevalainen, P. I., & Moilanen, T. (2015). Diabetes is associated with persistent pain after hip and knee replacement. Acta orthopaedica, 86(5), 586-593.

Uesugi, K., Kitano, N., Kikuchi, T., Sekiguchi, M., & Konno, S. I. (2014). Comparison of peripheral nerve block with periarticular injection analgesia after total knee arthroplasty: a randomized, controlled study. The Knee, 21(4), 848-852.

Webb, M. L., Golinvaux, N. S., Ibe, I. K., Bovonratwet, P., Ellman, M. S., & Grauer, J. N. (2017). Comparison of perioperative adverse event rates after total knee arthroplasty in patients with diabetes: insulin dependence makes a difference. The Journal of arthroplasty, 32(10), 2947-2951.

Wylde, V., Beswick, A., Bruce, J., Blom, A., Howells, N., & Gooberman-Hill, R. (2018). Chronic pain after total knee arthroplasty. EFORT open reviews, 3(8), 461-470. doi:10.1302/2058-5241.3.180004

Zhang, Y. M., He, J., Zhou, C., Li, Y., Yi, D. K., & Zhang, X. (2015). Acute hypotension after total knee arthroplasty and its nursing strategy. International journal of clinical and experimental medicine, 8(8), 13946-53.

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