Anesthesia and Pain Management
An important aspect of the Dorr Institute program is anesthesia care - during surgery, recovery and the first days in rehabilitation. Our goal is to reduce your anxiety and keep you safe and comfortable throughout your hospital stay. We will stay by your side through the surgery, monitoring and observing from the time you go to sleep until you are safely awakened and in the recovery room. After surgery, our anesthesiologists remain involved in pain control to help speed recovery. There are common side effects from anesthesia, including nausea and dizziness, and our anesthesiologists take preventative measures to help minimize these sensations.
We have a dedicated group of specialist physician anesthesiologists who provide services exclusively for patients undergoing many types of orthopaedic surgery, including joint replacement surgery. Of interest to many patients is that our team of anesthesiologist is particularly experienced in treating older patients, many of whom often have health concerns unrelated to their surgery, such as high blood pressure or heart disease. During your Pre-Op class you will learn more about anesthesia and much more to help you be confident, well-informed, and comfortable.
Anesthesia for total hip and knee arthroplasties
The preferred method for total hip or total knee replacement at the Arthritis Institute is the combination of epidural anesthesia with deep intravenous sedation.
Epidural anesthesia is administered via a very small catheter (approximately 5 times the diameter of a human hair) inserted in the epidural space of the lumbar spine. The epidural space surrounds a membrane called dura mater that encloses the spinal cord. Nerve roots travel in this space.
Local anesthesia injected in the epidural space will block sensation, or sensation and motor coordination depending on the amount of a novocaine like drug used.
During surgery, epidural anesthesia is supplemented with intravenous sedation. This is accomplished by continuous injection of propofol medication that will keep the patient unconscious for the duration of the procedure.
After surgery, patients will recover faster and without the usual side effects associated with general anesthesia like nausea, vomiting, and dizziness. We try to avoid this side effect by using general anesthesia as a last option and by avoiding intravenous narcotics. There are also some important advantages that make epidural anesthesia the clear choice for these surgeries, such as reduction in the amount of blood loss and the reduction in the incidence of blood clots. Finally, we prefer epidural to spinal anesthesia because: 1) the use of an epidural catheter allows better control of the sensory level and duration of anesthesia; 2) the blood pressure drop associated with epidural anesthesia is more gradual and easier to control than that of spinal anesthesia; and 3) severe and rare complications such as post-dural puncture spinal headache are reported with spinal anesthesia.
FAQ to our Anesthesiologists
Will you be taking care of me during the entire operation?
Absolutely! Your anesthesiologist never leaves your bedside while you are asleep. You are continually monitored from the time you go to sleep until you are safely awakened in the recovery room. You are never left alone.
I have diabetes (or high blood pressure, or angina, or asthma, or a heart condition, or.). Will I be able to have surgery?
A significant number of our patients do have additional medical problems, and these are thoroughly investigated prior to surgery. We have considerable experience with older, less healthy patients, and perform surgery only when appropriate and safe. We routinely monitor all vital signs like blood pressure, breathing, pulse rate, oxygen concentration, fluid intake, body temperature, blood sugar and urine production during your procedure.
I am afraid to see the operating room. Can you give me medication to calm my nerves.
Most patients have little or no recall of when they went into the operating room. Although you will not be asleep when you enter the operating room, if you are nervous, we can often provide a small dose of a relaxant and anti-anxiety drug to help.
When will I be awakened after surgery?
After the surgery is completed. Some patients may take a little longer to wake up than others, but that is simply because some people are more sensitive to medication. We stay with you until you are safely in recovery.
The Arthritis Institute pain protocol is multimodal, where more than two analgesic agents with different modes of action are used. We believe it is easier to prevent pain and inflammation at the central and peripheral level than it is to reduce it once it is established. For central modulation, we use opiates, an epidural, and COX-2 inhibitors. Locally, we use femoral nerve catheters and injections.
Once tissue is damaged, noxious stimuli are produced and initiate a response from peripheral sensory neurons to release neurotransmitters in the dorsal horn neurons of the spinal cord. Acute pain is produced when these neurotransmitters relay the sensory information to the thalamus. If inflammation is treated appropriately, then normal hypersensitivity will resolve without causing major biochemical changes. If inflammation persists, an alteration in receptors occurs and causes an increased sensitization of peripheral sensory neurons where COX-2 is induced in dorsal horn neurons, the thalamus, ventral midbrain, and pons.
Preoperatively, we use three medications to prevent post-operative pain. Oxycontin (10 mg) is an opiate that mimics the actions of endogenous opioid peptides within the central nervous system. When the medication activates the mu opioid receptors, excitatory pathway transmission of acetylcholine, serotonin, and substance P (a neuropeptide active in neurons that mediate pain sensation) is inhibited. Celebrex (400 mg) is used to decrease inflammation and pain by selectively inhibiting the COX-2 isoenzyme and prostaglandin production. Tylenol (500mg) affects the COX-2 receptors and elevates a patient's pain threshold. In order to prevent stomach irritation from these three pain relievers, we give one dose of the proton pump inhibitor Prevacid (30 mg).
During the operation, we use medications to produce a local response. An epidural with ropivacaine is used along with propofol. Please see anesthesia section for more details. For both the hip and knee patients, a cocktail of ropivacaine (100 mg), morphine (4 mg), Depo Medrol (40 mg), and saline is injected into the joint to prevent peripheral sensitization. This prevents local inflammation with the Depo Medrol and pain by stimulating the mu receptors with morphine. Previously, we also used epinephrine in the injection; however, many of our patients showed arrhythmias. Without the epinephrine, we haven't seen any more problems. For knee replacements, we place an indwelling femoral nerve catheter for 1-2 days with a continuous infusion of ropivicaine 0.25% at 5 cc/hour. This catheter prevents pain along the femoral nerve distribution and allows for patients to move around comfortably immediately after surgery.
In the recovery room, if the patient is having mild pain, we give the NSAIDToradol (15-30 mg IV, depending on age and creatinine level) to prevent the formation of prostaglandins and decrease inflammation. For moderate to severe pain, we give a fast-acting OxyIR (5mg by mouth) to activate the mu opioid receptors.
Once the patient is transferred to the floor, we continue the COX-2 inhibition by giving Celebrex 200 mg daily for a total of two weeks. Knee patients begin Celebrex on POD #2after they have received Toradol every six hours for 48 hours. Hip patients begin on POD #1. For the first two nights, a combination of an opiateand Tylenol is given every four hours from 6 pm-6 am. Patients under 65 years old take Norco and Tylenol and those above 65 years old take Darvon and Tylenol. During the rest of the hospitalization, patients take either Norco, Vicodin, or Darvocet as needed for pain, depending on tolerability.
Through our research, we have found that this protocol prevents the onset of pain for most of our patients, as well as the nausea, dizziness, and vomiting associated with intravenous narcotics. Our patients are able to ambulate the day of surgery without pain and tend to leave the hospital at a much faster rate.
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