From the Guidelines
Severe pain post knee replacement should be treated with a multimodal approach, including general anaesthesia combined with a femoral nerve block or spinal anaesthesia with local anaesthetic plus spinal morphine, supplemented with paracetamol, non-steroidal anti-inflammatory drugs, and intravenous strong opioids. When managing severe pain after knee replacement, it's essential to consider the most recent and highest quality evidence, which suggests that a combination of analgesic, anaesthetic, and surgical interventions can provide effective pain management 1. Some key considerations for treatment include:
- Using general anaesthesia combined with a femoral nerve block for surgery and postoperative analgesia
- Alternatively, using spinal anaesthesia with local anaesthetic plus spinal morphine
- Supplementing the primary technique with cooling and compression techniques
- Adding paracetamol and conventional non-steroidal anti-inflammatory drugs or COX-2-selective inhibitors to the treatment regimen
- Using intravenous strong opioids for high-intensity pain or weak opioids for moderate- to low-intensity pain, as recommended by the PROSPECT Working Group 1. It's crucial to prioritize a multimodal approach to target different pain pathways and minimize the risk of complications, such as excessive swelling, fever, or worsening pain. By following this approach, patients can experience improved pain management and a better quality of life after knee replacement surgery.
From the FDA Drug Label
Oxycodone hydrochloride tablets are an opioid agonist indicated for the management of pain severe enough to require an opioid analgesic and for which alternative treatments are inadequate The answer to treating severe pain post knee replacement is to use oxycodone if alternative treatments are inadequate, and the patient has not been able to tolerate or receive adequate analgesia from non-opioid options.
- Key considerations:
- Reserve oxycodone for patients who have not tolerated or are not expected to tolerate alternative treatments
- Reserve oxycodone for patients who have not received adequate analgesia from alternative treatments
- Be aware of the risks of addiction, abuse, and misuse with opioids, even at recommended doses 2
From the Research
Treatment Options for Severe Pain Post Knee Replacement
- Pharmacologic management of acute pain should be tailored for each patient, including a review of treatment expectations and a plan for the time course of prescriptions 3
- For severe or refractory acute pain, treatment can be briefly escalated with the use of medications that work on opioid and monoamine receptors (e.g., tramadol, tapentadol) or with the use of acetaminophen/opioid or NSAID/opioid combinations 3
- Paracetamol and nonsteroidal anti-inflammatory or cyclo-oxygenase-2-specific inhibitors are recommended for pain management after total knee arthroplasty, combined with a single shot adductor canal block and peri-articular local infiltration analgesia together with a single intra-operative dose of intravenous dexamethasone 4
Non-Opioid Alternatives
- Acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) are first-line treatment options for most patients with acute mild to moderate pain 3
- NSAIDs and acetaminophen can effectively replace opioid treatment options for acute pain, although these agents are not without risks 5
- Combination therapy using a small amount of opioid together with a nonopioid pain reliever has been shown effective and reduces opioid consumption 5
Risks and Considerations
- Nonselective NSAIDs should be used with caution in patients with a history of gastrointestinal bleeding, cardiovascular disease, or chronic renal disease 3
- The use of opioids even for acute pain of short duration has been questioned, and short-term use of opioids under close clinical supervision may be appropriate 5
- Coprescribing proton-pump inhibitors with nonsteroidal anti-inflammatory drugs may potentiate gastrointestinal risks associated with NSAIDs 6