An official website of the United States government
Official websites use .gov
A
.gov
website belongs to an official government organization in the United States.
Secure .gov websites use HTTPS
A lock
()
or
https://
means you’ve safely connected to the .gov website. Share sensitive information only on official, secure websites.
SHARE:
Event 2: Marty's Journey
Primary Care
Surgical Education
Pre-Op
Post-Op
Follow Up
Plan Marty's Pre-Op Pain Care
Potential Treatments
Provide 225mg PO venlafaxine 2-3 hours prior to first incision with small amount of water.
Marty is currently on fluoxetine 40 QAM and tramadol 50mg Q6 hours as needed. Serotonin syndrome may be a concern here. Additionally, she has been on venlafaxine in the past, yet we do not know why it was discontinued (efficacy versus tolerability). Currently, data is lacking for venlafaxine dosing prior to total knee arthroplasty (TKR). Positive data for pre-emptive analgesia with venlafaxine is limited to mastectomy surgeries.
Duloxetine, a similar drug pharmacologically, has been shown to reduce pain scores and opioid utilization when given prior to TKR surgeries.
Given the above information, venlafaxine would not be recommended at this time as pre-emptive analgesia.
Provide 300mg PO pregabalin 2-3 hours prior to first incision with small amount of water.
Pregabalin would be a reasonable consideration for Marty prior to her surgery. Positive data exists to suggest pre-operative pregabalin reduces post-operative morphine consumption and passive knee flexion range following total knee replacement. Pregabalin has also been studied for pre-emptive analgesia in other surgical models both alone and in combination with other neuromodulators or nonsteroidal anti-inflammatory drugs.
Discontinue tramadol 1-2 weeks prior to planned procedure to ensure patient is opioid naive.
Marty is currently taking tramadol "as needed." Unfortunately, there is a paucity of data on the role of opioid tapering prior to surgery and its impact on post-operative scores or opioid consumption. Many patients will find difficulty in tapering or, alternatively, will push back significantly.
Until more data is available to guide the impact of opioid tolerance versus opioid naive state going into a surgical procedure, the clinician should weigh the risks versus harms carefully with the patient.
Discuss realistic expectations of post-op pain levels, appropriate self-treatment modalities, and rehab importance.
While it is advisable to provide pre-operative education to patients, in terms of orthopedic surgeries, data suggests that only pre-operative anxiety levels are affected positively.
Post-operative pain, range of motion, and length of stay do not appear to be impacted by pre-operative education for some orthopedic surgery types.
For cholecystectomy same-day surgeries, pre-operative education on pain and expectations did decrease pain, side effects, and return to regular activities. Considering pre-operative anxiety levels can predict post-operative outcomes, this practice should be considered, especially as part of a comprehensive ERAS program.
Educate on the proper use of patient-controlled analgesia devices, requesting as needed pain meds, etc.
Explaining the post-operative period to the patient prior to the day of surgery has beneficial effects. Proper instruction on the use of patient controlled analgesia, if used, may reduce adverse drug events. Additionally, actual pain severity and opioid consumption may be reduced in select surgical procedures.
