Hip and knee replacement surgery is becoming increasingly successful in alleviating pain and immobility. But postoperative pain continues to be undertreated despite the existence of pain management guidelines, and the fear of pain leads some patients to forego the surgery, Jaime Baker, MD, from Ohio State University Medical Center in Columbus, reported at the "Hospital Medicine 2010: Society of Hospital Medicine (SHM) Annual Meeting."
Dr. Baker was the lead investigator of a retrospective chart review study of pain scores and medications administered to 34 patients undergoing total hip anthroplasty and 66 patients undergoing total knee anthroplasty. Dr. Baker presented her findings here at a poster session.
The key objective of the study was to determine if the treatment followed American Pain Society (APS) guidelines, which include the administration of 200 mg of celecoxib (Celebrex) twice daily after surgery, along with acetaminophen and scheduled narcotics. Pain scores were significantly lower for patients receiving celecoxib. The need for self-administered narcotics was also significantly lower with regular administration of the nonsteroidal anti-inflammatory drug (NSAID).
On a scale of 1 to 10, the patients who did not receive NSAIDs reported much higher pain levels than those who did. The chart review examined information for each patient for the three days after surgery. Patients were asked to record their perceived pain at hourly intervals. Both ordered and administered medications were documented on the chart. Nearly all patients (95%) also received narcotics, either through patient-controlled analgesia or patient-controlled epidural analgesia. Dosages were converted to oral morphine equivalents.
On day 1, 73% of patients reported a pain score of 4 or higher at least one time during the day, and many reported a higher score for longer periods of time. Dr. Baker found that pain scores ranged from 6 to 10 for each hour during the day.
"Of the 22 patients receiving the recommended scheduled multimodal therapy, none reported pain scores higher than 4. The average amount of morphine equivalent used was 118 mg, compared with 172 mg in the non-NSAID group," Dr. Baker and colleagues found.
The self-reported level of pain for patients receiving celecoxib ranged from 0 to 3 throughout the day. Data showed the same results on day 2: 28% of patients in the non-NSAID group had a pain score higher than 4 and none of the patients in the NSAID group reported a score higher than 4.
Narcotic use was similarly reduced in the NSAID group, with patients self-administering a 65 mg morphine equivalent on the second day after surgery, compared with patients who were taking only acetaminophen and narcotics. The average morphine-equivalent dose taken by the non-NSAID group was 82 mg.
Another statistic from the chart review that caught Dr. Baker's eye was the fact that more than half (51%) of the hospitalists following these patients mentioned pain in the chart and 40% deferred the issue of pain control back to the orthopedic team.
"The real irony here is that there are guidelines out there that work but they are not known to physicians and, therefore, are not being appropriately used," said Dr. Baker.
"This study is a classic example of the diffusion of innovation," Danielle Scheurer, MD, physician spokesperson for SHM and a hospitalist at Brigham & Women's Hospital in Boston, Massachusetts, told Medscape Internal Medicine. "Clearly the [APS] guidelines are evidence-based, but like other guidelines, they are slow to seep into daily clinical practice," said Dr. Scherer. "This study shows how we can transfer knowledge from the bench to the bedside," she said.
Dr. Baker told Medscape Internal Medicinethat some orthopedic surgeons are reluctant to use NSAIDs because of the known higher risk of bleeding following total hip anthroplasty and total knee anthroplasty. But unlike other NSAIDs, which can cause an increase in bleeding, celecoxib does not, she noted.
Celecoxib used according to the APS guidelines is safe and effective, Dr. Baker asserted, but she acknowledged that it is not recommended for patients on warfarin therapy or with a creatinine level higher than 1.5 mg/dL.
Physicians at the University of Denver Medical Center, where this study was conducted, have been following the APS guidelines for two years now. There have been no adverse events or any evidence of increased risk to patients during this time, said Dr. Baker.
"Significant room for improvement in pain awareness, guideline concordance, and pain treatment exists," she concluded.
The study did not receive commercial support. Dr. Baker and Dr. Scheurer have disclosed no relevant financial relationships. Hospital Medicine 2010: Society of Hospital Medicine (SHM) Annual Meeting. Abstract 18. Presented April 9, 2010.
Terry Hartnett • Medscape Medical News © 2010 Medscape, LLC