A Case for Multi-modal Pain Management in the Elderly Patient
Michael P. Bolognesi, MD
An 89-year-old female presented with progressive pain, decreased function, and radiographic evidence of advanced degenerative joint disease affecting both of her knees. The patient failed to improve with conservative treatment options and elected to pursue total joint replacement. The conservative treatment options included assistive aid, NSAIDS, injections, and activity modification. The risks, benefits, and alternatives to surgery were clearly explained and she had a good understanding of the operation. One of the main concerns with a patient of this age is the ability to limit the amount of oral narcotics given the risk of numerous side effects including confusion, nausea, constipation, and altered appetite.
The patient was seen in the Pre Anesthesia Testing Clinic (PAT). A plan was formalized to use a regional technique with local blocks in conjunction with a multi-modal technique in regards to oral and IV adjunctive medications. In the pre-op holding area, spinal was placed at the L3-4 location with a single shot technique using a 22 G Quincke needle (100 mm length). The block drug was Isobaric bupivacaine at a concentration of 0.5%.
Posterior Capsular Block
The patient was placed in a supine position and the approach to this block was lateral. This was an ultrasound guided technique and is also referred to as a IPACK block. A 21 G Stimuplex needle was utilized and ropivicaine at the concentration of 0.25% with epinephrine 1:400K was the agent selected. The total volume injected under ultrasound visualization was 20mL.
Adductor Canal Block with Catheter
The patient remained in the supine position; an anterior approach and ultrasound guidance were used. The needle selected was an 18 G insulated, stimulating Tuohy needle 100m in length. The block drug was ropivicaine again at a concentration of 0.25% with epinephrine 1:400K. The total volume used was also 20mL. An indwelling catheter was placed. A sterile adhesive dressing was applied and positioned in such a way that it was covered by the tourniquet and out of the way of the sterile field.
The patient underwent an uncomplicated total knee arthroplasty. The operation itself was uneventful with 50 cc of blood loss. Intravenous TXA was used at a dose of 1 gram prior to incision and another dose at tourniquet release. The patient was able to ambulate 100 feet POD#0 on a walker.
The patient received IV dexamethasone (10 mg) pre-operatively as well as 24 hours later. Pre-emptive antiemetic treatment was initiated using a scopolamine patch pre-operatively. Oral and IV antiemetics were also ordered post-operatively on a PRN basis. The medication regimen we have in place on the floor is listed below.
- Acetaminophen 650mg q6
- Gabapentin 400-600mg q8 or Lyrica 100mg Q12 is an alternative
- Celebrex 100-200 mg Q12
- Oxycodone 5-15mg Q4h PRN
- Dilaudid 0.5mg iv Q3h PRN for breakthrough severe pain.
- Oxycontin 10mg Q12 (MS contin 30mg Q12 BID). CAUTION only occasional use.
This patient did not receive Oxycontin given her age and we used gabapentin as opposed to Lyrica due to concerns about insurance approval. We also did not use any Dilaudid IV for breakthrough. The patient received a total of four 5 mg oxycodone tablets during her 2 night stay in the hospital.
The patient went home on a similar regiment of medications. We made sure to continue the acetaminophen, anti-inflammatory medications, and gabapentin. This patient required very little oral narcotic at home (oxycodone 5 mg) and reported only using 5-6 tablets over the first few days at home.
Transition to Home Pump
This patient’s adductor canal catheter was connected to a continuous infusion pump running at 8 ml/hr in the hospital. Prior to discharge on POD #2, the Anesthesia Pain Service transitioned her to a home infusion pump that is portable in nature. This elastomeric pump automatically and continuously delivers a regulated flow of local anesthetic via the adductor canal catheter. The patient is able to remove the catheter at home after receiving simple instructions from the APS team. There is also a 24 hour call line for questions related to the pump and patients are advised about how to take oral pain medications prior to removal.
This patient had an excellent post-operative course and decided to have her other knee replaced approximately 4 months later. An identical technique was utilized and this time the patient was able to leave POD#1. There are numerous ways to perform multi-modal anesthesia and we certainly believe that this is not the only approach that should be used. Pericapsular injections as opposed to blocks may be able to deliver similar excellent results. We do feel strongly about using these techniques to avoid general anesthesia especially in this patient age group. We hope these techniques allow for better pain control, earlier ambulation, and a likely decreased length of stay without compromising patient outcomes and experience.