<strong>Notas</strong> / <strong>Notes</strong> MIÉRCOLES / WEDNESDAY 77
MIÉRCOLES / WEDNESDAY 78 RAPID RECOVERY THR: PAIN, ANESTHESIA, PAIN MANAGEMENT, AND SAME DAY DISCHARGE Aditya Vikram Maheshwari, M.D., Myriam Boutary, BS, Andrew G. Yun, M.D., Leigh Ellen Sirianni, OPAC, and Lawrence D. Dorr, M.D. Medical Director Arthritis Institute Centinela Hospital, California (USA) Methods for managing pain after a total hip replacement have changed substantially in the past 5 years. We documented the outcome of patients treated with a multimodal pain program designed to avoid parenteral narcotics. Avoidance of parenteral narcotics can essentially eliminate the complications of respiratory depression, ileus, and narcotic induced hypotension. It can minimize nausea and vomiting which cause dissatisfaction with an operation. Twenty-one of 140 patients (15%) needed parenteral narcotics postoperatively with only nine patients (6.4%) using parenteral narcotics after the day of surgery. Mean pain scores were below 3 of 10 on all postoperative days. There were no patients with respiratory depression or ileus, and four (2.9%) with urinary retention. Nausea occurred with 35 patients (25%) in the recovery room and in 28 patients (20%) thereafter. Emesis occurred in five patients (3.6%) with two incidences in the recovery room. One hundred and thirty-eight patients (98.6%) were discharged home at a mean of 2.7 seven days postoperatively with 98 (70%) on a single assistive device. The multimodal pain management program, which avoided parenteral narcotics, was effective in providing pain relief, nearly eliminating emesis, and eliminating the severe complications of respiratory depression, urinary tract infection and ileus, as well as accelerating function. Appendix. Medications for Multimodal Pain Program for Total Hip Replacement Note: Patients do NOT need to stop Celebrex before surgery Preoperative (morning of surgery) 1. OxyContin, 10 mg PO 2. Celebrex, 400 mg PO (if allergic to sulpha, then no NSAIDs) 3. Tylenol, 500 mg PO 4. Prevacid, 30 mg, PO 5. If allergic to sulpha drugs, Limbrel, 1000 mg Recovery room 1. For bilateral hips, keep epidural catheter capped until transferred to floor 2. For primary hips, pull epidural catheter in operating room 3. ASA, 600 mg per rectum 4. Toradol, 30 mg IV x 1 dose as needed for mild to moderate pain (15 mg IV if older than 65 years) 5. OxyIR, 5 mg PO as needed for severe pain 6. Ice applied to operated hip Floor program 1. If younger than 65 years, Norco, 10 mg, 1 tab PO, alternating with Tylenol ES, 500 mg PO every 4 hours from 6 PM to 6 AM x 2 days 2. If older than 65 years, Darvon, 65 mg, 1 tab PO, alternating with Tylenol ES, 500 mg PO every 4 hours from 6 PM to 6 AM x 2 days 3. Celebrex, 200 mg PO twice daily, starting postoperative day 1, or Lembril, 500 mg PO twice daily 4. Vicodin, 5mg/500mg, 1-2 tab PO every 3-4 hours as needed for pain 5. Norco, 10mg/325mg, 1-2 tab PO every 3-4 hours as needed for pain 6. Darvocet N-100, 1 tab PO every 4 hours as needed for pain (if older than 65 years) 7. Ultram, 50 mg, 1 tab. PO every 4-6 hrs as needed for pain 8. Ancef (cefazolin), 1 gm IVPB every 8 hours x 24 hours 9. Anzemet, 12.5 mg IV every 6 hours x 24 hours 10. If reflux disease, Zofran, 4 mg IV every 6 hours x 24 hours (instead of Anzemet) 11. Reglan, 10 mg IV, IVP every 8 hours x 48 hours 12. Enteric coated acetylsalicylic acid (ECASA), 325 mg 1 tab PO twice daily 13. Milk Of Magnesia 30 ml every 8 hours 14. Colace, 100 mg PO twice daily 15. Dulcolax suppository per rectum daily as needed for constipation 16. Prevacid, 30 mg PO twice daily 17. Dietary for food preferences 18. Regular diet 19. Cream of wheat for breakfast daily to avoid need for iron tablets Discharge 1. Celebrex, 200 mg PO twice daily x 21 days (total of 3 weeks) or Lembril, 500 mg PO twice daily 2. ECASA, 325 mg 1 tab PO twice daily (for 30 days after surgery) 3. Prevacid, 30 mg twice daily (while on ECASA) Pain medications (whatever patient was on while in hospital)