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Requirement
"comparison between two postoperative pain management methods for total knee replacement"
it is an assignment for critical appraisal of three published articles comparing two analgesic methods after total knee replacement in 2500 words.
my research QUESTION is
"Can LIA be a more effective method than CFNB for postoperative pain management among adults undergoing TKR in terms of pain intensity, early mobilization and length of hospital stay?"
Comparison of postoperative pain management methods for total knee
replacement: Critical Appraisal
Solution
1. Introduction
The impact of musculoskeletal (MS) conditions is considered as pervasive. They are the most common cause of severe long-term pain and physical disability, and they affect hundreds of millions of people around the world. They significantly affect the psychosocial status of affected people as well as their families and carers (Woolf & Akesson, 2001). The MS becomes a burden to the common public from treatment and psychology perspective. The disorders are expected to be increased across the world. According to the report (Orthopedic disorders, 2016), the prevalence in the United States of America is approx 1 in 6 or 14.90% or 40.5 million people. From the statistics, it can be understood that the severity of the disease. The symptoms of MS can be treated to some extent utilizing medication however, in severe cases the surgical procedures are only the choice of modality of treatment (Cury et al., 2015). Among the cases, total knee replacement (TKR) could mitigate the symptoms and provide long term relieve from pain. The cost of such procedures is associated with huge expenses. Despite of high cost of treatment, TKR is associated with abundant pain after surgical procedures. Diverse modes are available to mitigate pain perception after surgery. The medical practitioners and surgeons chose diverse approaches for the monitoring of postoperative pain. The
selection criteria are not clear and each mode is associated with certain merits and demerits. To understand the procedures, the present paper aimed to compare the salient aspects of approaches based on literature search and pieces of evidence. More emphasis would be given for selected approaches i.e., local infiltration analgesia and continuous femoral nerve block in order to identify the best approach for pain suppression.
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2.0 Search strategy
The available and popular sources were used to search for the pieces of evidence. The sources, diverse online electronic resources including ScienceDirect, SpringerLink, Wiley science, Pubmed, and The DARE (Database of Abstracts of Reviews of Effects) were utilized for the search of evidences. Initially the search was begun and done for the past 30 years, eventually filtered by choosing selective and specific ‘keywords’ to the present context. In addition, the
available textbooks (pharmacology, nursing, health education) from the library were also searched for the pieces of evidence. Satisfactory safety measures were made to channel the quest for the pertinent sources. The keywords utilized for the pursuit incorporate ‘total knee replacement (TKR), postoperative pain management, novel methods of analgesia, nerve block, local analgesia etc’. The outcome of the search and most relevant sources are sorted
out and in detail, a description is provided in subsequent sections. Most sources are focusing on the strategies of local infiltration analgesia (LIA) and continuous femoral nerve block (CFNB) as the approaches for pain management. Therefore, to under the effectiveness of LIA over CFNB, a comparison is made for the features of both the methods. Accordingly, the research question is framed as "Can LIA be more effective method than CFNB for postoperative pain management among adults undergoing TKR in terms of pain intensity, early mobilization and length of hospital stay?"
2.0. Critical appraisal
The available sources have been filtered in order to search for the pieces of evidence and find the most relevant one. Among the articles three articles appear to be more relevant therefore the articles are reviewed and subjected for critical appraisal as follows
2.1. Article-1
One article (Carli et al., 2010) describes the efficacy of analgesic modes on the recovery after surgery for the ability to walk in patients with total knee arthroplasty (TKA). The study was based on a randomized controlled trail with balanced blocked control at one study center. The patients from other centers should have been considered to be included to minimize the bias. The investigators have taken necessary ethics permission for the conduct of study. But the study was not registered in the clinical trial database. A system of inclusion and exclusion criteria was followed. Only one criterion was mentioned for the inclusion i.e., patients over 18 years with a history of TKA. Patients with liver, heart and/or kidney failure or organ transplant were excluded from the study. However, it does not mean that patients with organ failure possess TKA. Patients with organ failure also suffer from TKA (Miric et al
2014) indicating that the exclusion criteria are not appropriate. The investigators should have considered TKA patients suffering from other disorders. A harmonized procedure for all the patients was followed in terms of anesthesia. Two analgesic techniques were employed in the investigation. One method was based on continuous femoral nerve block (CFNB) and the second one is local infiltration analgesia. To achieve the nerve block, a catheter is inserted under aseptic conditions. The catheter was threaded to maintain the desired motor response. The procedure used appears to be a known procedure and is being in practice (Albrecht et al., 2014) however; it was not clear from the method for the duration of procedure i.e., how long the nerve block was done using the catheter. The anesthetic agent (ropivacaine), analgesic (ketorolac) and epinephrine were administered in to posterior capsule of the knee as an infiltrate and periarticular and intraarticular infiltrate. The infiltration was done for all the patients despite of marginal proportion of pain (about 15-20% of patients suffer from popliteal pain). The second method that was chosen for pain relief was administration of high dose of anesthetic, analgesic and vasoconstrictor. The pain was further mitigating by administering morphine. Based on the evidences, the provided methods are not clear and are difficult to understand. For instance, it is hard to find the sample size in the methods section. The authors should have followed established guidance in providing the methods for clinical trials. Kao et al (2008) described the methods of clinical research based on randomized trials. In fact, the sample size justification is partial and more details should have been given, as the sample size should be adequate in order to meet the power criteria and trust the results. Suresh et al., (2011) proposed the ways for the data analysis including the sampling methods for clinical research. The authors utilized advanced methods of statistical testing for the assessment of significance. However, detailed elaboration of the explanation for the results is missing. The outcome of the study reveal that CFNB has showed a significant reduction of pain i.e., better analgesia in comparison to periarticular infiltration. It indicates that the functional recovery at 6 weeks after surgery was more favorable in the CFNB group. The authors failed to describe the underlying mechanisms of how CFNB is showing better response than
periarticular filtration. // To Be continued in the final solution.
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Affas, F., Nygårds, E.-B., Stiller, C.-O., Wretenberg, P., & Olofsson, C. (2011). Pain control after total knee arthroplasty: a randomized trial comparing local infiltration anesthesia and continuous femoral block. Acta Orthopaedica, 82(4), 441–447. http://doi.org/ 10.3109/17453674.2011.581264 Albrecht, E., Morfey, D., Chan, V., Gandhi, R., Koshkin, A., Chin, K. J., … Brull, R. (2014). Single-injection or Continuous Femoral Nerve Block for Total Knee Arthroplasty? Clinical Orthopaedics and Related Research, 472(5), 1384–1393. http://doi.org/10.1007/s11999-013-3192-3 Carli, F., Clemente, A., Asenjo, J.F., Kim, D.J., Mistraletti, G., Gomarasca, M., Morabito, A & Tanzer, M (2010) Analgesia and functional outcome after total knee arthroplasty: periarticular infiltration vs continuous femoral nerve block. Br J Anaesth. 105(2):185-95. doi: 10.1093/bja/aeq112. Epub 2010 Jun 14.Chien, C.W., Bagraith, K.S., Khan, A., Deen, M & Strong, J (2013) Comparative responsiveness of verbal and numerical rating scales to measure pain intensity in patients with chronic pain. J Pain. 14(12), 1653-62. doi: 10.1016/j.jpain.2013.08.006.4 Cury, R. de P. L., Cinagawa, E. H. T., Camargo, O. P. A., Honda, E. K., Klautau, G. B., &
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