Background: Postoperative pain after a total knee arthroplasty (TKA) is a major concern for the patient and nurse. Pain after a TKA can be severe and, when inadequately controlled, can impair or prevent functional rehabilitation with physiologic, psychologic, and economic consequences (Sawyer, 2004). With multiple pain management regimens, healthcare providers need data on approaches that provide optimal postoperative pain relief with minimal side effects.

There are more than 100 different types of arthritis. One in five adults or approximately 46 million Americans have reported that they have doctor-diagnosed arthritis (Centers for Disease Control and Prevention, 2009). Osteoarthritis (OA) is the most common form of noninflammatory arthritis, is prevalent among individuals aged 60 years and older, and is widespread across all cultures (Burks, 2005). Osteoarthritis can affect weight-bearing joints (hips and knees) and joints that are non-weight-bearing (hands and elbows; Burks). This noninflammatory disease causes cartilage degeneration, subchondral bone erosion, and osteophyte production, which can lead to joint destruction and deformity (Osterman, Raphael, & Neal, 1997). A total knee arthroplasty (TKA) may be indicated for individuals diagnosed with OA that was unresponsive to conservative treatments, such as nonpharmacologic (e.g., cold therapy and support devices) and pharmacologic methods (e.g., acetaminophen, nonsteroidal anti-inflammatory drugs, and steroids; McCaffery & Pasero, 1999). A TKA is a surgical procedure that involves removing the diseased ends of the distal femur and proximal tibial plateau and replacing them with metal and plastic prostheses (Davis & Abbate, 2007). The long-term goals of a TKA are pain relief and improved function in activities of daily living (Dauty, Genty, & Ribinik, 2007).

Approximately 320,000 people in the United States had a TKA in 2002 (Dauty et al., 2007), and this number is projected to increase because of the aging population. In 1998, there were 34 million adults aged 65 years and older (Federal Interagency Forum on Aging-Related Statistics, 2000). By the year 2030, the entire cohort of "baby boomers" will be 65 years of age or older, which is estimated to double the number of older adults to approximately 70 million (Federal Interagency Forum on Aging-Related Statistics).

Postoperative pain after a TKA is a major concern for the patient and the nurse. Pain after a TKA can be severe and, when inadequately controlled, can impair or prevent functional rehabilitation with physiologic, psychologic, and economic consequences (Sawyer, 2004). Many types of regional anesthetics were developed and are available for postoperative TKA pain management (Capdevila, Coimbra, & Choquet, 2005). Little is known, however, about what combination of regional anesthetics provides the best pain control with the least amount of side effects. Thus, the purpose of this retrospective study was to examine whether there were differences between four combinations of anesthetics typically used for TKA in their ability to control postoperative pain and in the frequency of specific side effects (e.g., pruritus, nausea and vomiting [NV], somnolence, hypoventilation, and hypotension). Specifically the study compared:

Acute pain is difficult to define and measure. Acute pain is not a thing that people have but a nociceptive stimulation that produces unpleasant physical or psychologic effects (Fordyce, 2001). Because pain is personal and subjective (Pasero, Paice, & McCaffery, 1999), McCaffery (1968) suggested that "Pain is whatever the experiencing person says it is, existing whenever the experiencing person says it does" (McCaffery & Pasero, 1999, p. 17).

Severe acute pain is typically reported by patients after a TKA (Bickler et al., 2006; Kardash et al., 2007; Ozen, Inan, Tumer, Uyar, & Baltaci, 2006). Acute pain is a personal experience resulting from tissue damage, inflammation, and/or a disease process of brief duration and usually stops when the underlying disease process resolves (Turk & Okifuji, 2001). Acute pain has no biologic function and can predispose patients to chronic pain syndromes (Pasero et al., 1999), induce stress that causes activation of the neuroendocrine stress response (Stevens, 1999), cause patients to experience anxiety and emotional distress (Polomano, Dunwoody, Krenzischek, & Rathmell, 2008), prolong recovery, increase hospital length of stay (LOS) and healthcare costs, and reduce patient satisfaction (Shang & Gan, 2003).

Observable behaviors of acute pain include limping, frowning, grimacing, crying, or rigid body posture (McCaffery & Pasero, 1999). Acute pain also stimulates the sympathetic nervous system, which causes temporary physiologic changes such as tachycardia, increased blood pressure, cutaneous pallor, diaphoresis, and vomiting (Dunwoody, Krenzischek, Pasero, Rathmell, & Polomano, 2008). In contrast to acute pain, patients with chronic pain usually do not present with signs of sympathetic nervous system activation (American Pain Society, 2008). This lack of objective signs may cause the inexperienced nurse to inadequately treat pain, thus resulting in unrelieved pain (American Pain Society). Because pain is an unpleasant and distressful personal experience (Cheng, Foster, & Huang, 2002), the patient's own verbalizations are the most reliable pain indicator. Subjective descriptors of acute pain may include sharp, dull, stabbing, burning, throbbing, and aching sensations (Coda & Bonica, 2001).

Pain is a multidimensional experience because it has nociceptive stimulation components and personal interpretations of pain (Pellino et al., 2005). These diverse experiences of pain have given rise to multiple pain management approaches, with each approach having its own perceived benefits and shortcomings. Aging is associated with comorbid disease and an increased sensitivity to medications and anesthesia. Thus, these pharmacologic and physiologic challenges necessitate choosing an anesthetic that has minimal side effects in older adults.

Postoperative pain relief can be achieved by numerous techniques such as intravenous (IV) analgesia (e.g., patient controlled analgesia), regional anesthesia (e.g., intrathecal and epidural), and peripheral nerve blocks (e.g., femoral nerve and brachial plexus). The most commonly used postoperative pain management following a TKA is IV administration of opioids, such as morphine sulfate and hydromorphone, because of its simplicity to administer (Allen, Liu, Ware, Nairn, & Owens, 1998). Unfortunately, parenteral opioids are commonly associated with inadequate pain relief and opioid side effects, such as somnolence, NV, and pruritus (Hebl et al., 2005). A regional blockade (insertion of a needle along the nerve sheath) can result in a sympathetic, sensory, and/or motor block, depending on dose, concentration, or volume of anesthetic (Brown, 2005). Intrathecal local anesthetics produce a reversible conduction blockade of afferent and efferent sensory and motor impulses along central and peripheral nerve pathways (Roussel & Heindel, 1999). Intrathecal opioid anesthetics bind to the opioid receptors in the dorsal gray matter of the spinal cord and decrease the neurotransmission of afferent pain fibers (Roussel & Heindel). The advantage of intrathecal opioid anesthetics over IV opioid administration is the generation of segmental analgesia by direct spinal action so side effects, such as NV that are commonly associated with the systemic route, are minimized or avoided (Markowsky, 1990). Morphine sulfate, a low lipid-soluble opiate analgesic, has a slow rate of uptake into the spinal cord and tends to linger in the cerebrospinal fluid (CSF) and accounts for the prolonged duration of action (Markowsky).

Peripheral nerve blocks can also be used for postoperative pain management after a TKA. A local anesthetic is injected along the nerve sheath and/or ganglia outside of the brain and spinal cord to decrease or eliminate nerve conduction. The knee is innervated by the femoral nerve, which is the largest branch of the lumbosacral plexus (Allen et al., 1998). The femoral nerve supplies the motor contraction of the iliacus, pectineus, and anterior thigh muscles (Hadz[modifier hacek]ic[spacing acute] & Vloka, 2004). The femoral nerve also supplies the cutaneous and articular branches to the front and inner thigh, leg and foot, and hip and knee (Hadz[modifier hacek]ic[spacing acute] & Vloka). Ozen et al. (2006) found that the use of a FNB led to a reduction in postoperative opioid administration and its associated side effects such as NV and pruritus. Peripheral nerve blocks are also devoid of regional anesthetic disadvantages, such as hypotension and spinal headaches secondary to dural puncture (Edwards, Pandit, & Popat, 2006).

A review of the research literature investigating the efficacy of different types of regional anesthetics was done to find out what is known and not known about this topic. A prospective, randomized, double-blind study by Riad, Williams, Musson, and Wheatley (2002) suggested that patients who had ITM had significantly lower pain scores on movement during the first 8 hr after unilateral knee arthroplasty. Yapici et al. (2008) conducted a prospective, randomized, double-blind, controlled study exploring pain management among 23 hospital inpatients who underwent primary elective coronary artery bypass surgery, and found that ITM provided profound postoperative analgesia. In a randomized double-blind study of 26 postoperative colorectal surgery patients, Beaussier et al. (2006) found that pain intensity and daily IV morphine consumption were significantly reduced 1-2 days after colorectal surgery in patients who received ITM. These studies highlight the versatility of regional blocks and indicate that ITM reduces pain and the need for breakthrough pain medications.

Femoral nerve block with local anesthetic has also been advocated to decrease opioid use and to provide adequate pain relief after a TKA (De Ruyter et al., 2006). In a prospective, randomized, double-blind, placebo-controlled study, Allen et al. (1998) found that a FNB is a useful analgesic adjunct for the immediate postoperative period after unilateral TKA. A retrospective patient record study by Duarte, Fallis, Slonowsky, Kwarteng, and Yeung (2006) suggested that patients who received a FNB had significantly less pain than patients who did not have a FNB. Lastly, in a prospective, randomized, two parallel group study of 34 patients undergoing one-sided TKA, Ozen et al. (2006) found that the single-shot FNB led to a significant decrease in postoperative morphine consumption and was associated with fewer side effects such as NV and hypotension. These studies highlight that patients who had a TKA with FNB anesthesia had better pain control and fewer opioid side effects than patients who did not have a FNB.

Another modality that may improve postoperative analgesia is the placement of a catheter that infuses local anesthetic into postsurgical wounds. A continuous wound catheter offers the potential to provide substantial analgesia, decrease postoperative opioid use and side effects, and can be used for several days and on an ambulatory basis (Liu, Richman, Thirlby, & Wu, 2006). Liu et al. (2006) performed a meta-analysis that encompassed 44 different randomized clinical trials that included 2,141 patients across a wide range of surgical procedures and found that continuous wound catheters decreased postoperative pain, reduced opioid use and side effects, increased patient satisfaction, and reduced hospital LOS.

Prescriptive theories were introduced in 1968 as a method to link theory, practice, and research. According to Meleis (2007), "A prescriptive theory should designate the prescription and its components, the type of client to receive the prescription, the conditions under which the prescription should occur, and the consequences" (p. 44). The Agency for Health Care Policy and Research clinical practice guidelines, as outlined in the Acute Pain Management: Operative or Medical Procedures and Trauma, served as a model for the development of Good and Moore's (1996), A Balance between Analgesia and Side Effects (BASE) Theory. Using practice guidelines, based on evidence from well-designed studies, to develop middle-range theories can offer more efficiency and prescriptive power than theories generated by literature reviews, field studies, or theories from other disciplines (Good & Moore, 1996).

Descriptive theories of pain such as Melzack and Wall's (1965) Gate Control Theory explain how peripheral stimulation is transmitted, modulated in the dorsal horn of the spinal cord, and acted upon by the action system within the body (Bonica & Loeser, 2001). The Gate Control Theory offers insight into how pain is physiologically transmitted and perceived by an individual and can be used by physicians to prescribe analgesics. However, the Gate Control Theory does not address factors in the nursing realm, such as holistic treatments and nursing therapeutics (Good, 2004).

Good and Moore (1996) conceptualized acute pain as occurring after surgery and having sensory and affective components. The sensory component of pain was described as the localized physical perception of discomfort occurring after surgery and was defined as "pain sensation" (Good et al., 2001). The affective component of pain was described as the psychologic interpretation of pain associated with the noxious stimulus and was defined as "pain distress" (Good et al.). The concept, side effects, was conceptualized as any unpleasant sensory and affective experienced associated with analgesics. Lastly, Good (2004) defined the concept, "balance between analgesia and side effects," as patient satisfaction with pain relief and absence of medication side effects. The BASE assumptions, as described by Good (2004), are as follows: (1) the physician and nurse work together to effectively manage acute pain; (2) systemic or regional opioids; (3) medications for analgesic side effects are given as needed; (4) patients are adults with ability to learn, set goals, and communicate with healthcare practitioners; and (5) nurses have current knowledge of pain education and management.

Good and Moore's (1996) BASE prescriptive theory was used as the theoretical framework in this study because (1) the population of interest were alert adults, (2) severe pain is typical after a TKA, (3) pain after a TKA is inadequately controlled by a single modality, and (4) pain medication side effects may prevent administration of additional analgesics and increasing analgesic dosages. Although Good and Moore (1996) conceptualized acute pain and medication side effects as having both sensory and affective components, this study defined acute pain and analgesic side effects utilizing the sensory component of each experience.

Operational Definitions

1. Total knee arthroplasty was a surgical procedure that involved removing the diseased ends of the distal femur and the proximal tibial plateau and replacing them with metal and plastic prostheses (Davis & Abbate, 2007).

2. Intrathecal morphine sulfate was produced by the one-time administration of morphine sulfate and local anesthetic injected into the CSF in the subarachnoid space. A spinal needle is usually inserted between lumbar space 2 and 4 with the patient lying either on one side or in a sitting position (Markowsky, 1990).

3. Femoral nerve block was produced by the administration of a single-shot of local anesthetic injected at the femoral crease to block the femoral nerve complex with the patient in the supine position (Hadz[modifier hacek]ic[spacing acute] & Vloka, 2004).

11. Nausea and vomiting was an unpleasant sensation usually preceding ejection of gastric contents through the mouth (Taber, 2009), which required any additional administration of an antiemetic (prochlorperazine maleate, ondansetron, or metoclopramide) in the first 24 hr postoperative TKA.

The participants in this sample (N [SUPERSCRIPT EQUALS SIGN] 257) had a mean age of approximately 66.3 years (range, 35-86) and were predominately female (n [SUPERSCRIPT EQUALS SIGN] 185; 72%) (see Table 1). Within the first 24 hr postoperative TKA, approximately one-half or more of participants across all four anesthesia groups had pain and received an opioid (see Table 3). The most frequently reported side effects were pruritus, NV, and hypotension (see Table 2).

Table 1. Sample Characteristics (

Table 2. Percentages of Side Effects in the First 24 Hours Postoperative TKA (

Table 3. Frequency of Patient Request for Opioids Within the First 24 Hr Postoperative TKA (

Differences Between Pain Across Anesthesia Types

Similar and disparate findings were found between the findings from this study and the reviewed literature. The participant demographic characteristics, such as age and gender, were similar to those of Duarte et al. (2006), Hebl et al. (2005), Kardesh et al. (2007), and Ozen et al. (2006). Although OA is common across many cultures and increases with age, OA in the knee joint occurs at an accelerated pace in women older than 50 years due to a complex interplay between systemic factors, such as age, postmenopausal estrogen deficiency, and biomechanical factors of injury, obesity, and muscle weakness (Godfrey & Felson, 2008; Leslie, 2000).

In contrast to this study's significant finding between ITM dose and NV, a prospective, randomized, double-blinded study by Girgin, Gurget, Turker, Aksu, and Gulhan (2008) suggested that patients who had ITM did not have significantly higher episodes of NV after undergoing an elective or cesarean delivery. In addition, Gehling and Tryba (2009) performed a meta-analysis that encompassed 28 publications that included 790 patients who received ITM and 524 patients who received a placebo and found that there was a relative risk of NV in patients who received a lower ITM dose (0.1-0.3 mg). Although these two studies support the advantage of utilizing ITM for postoperative analgesia because of the low incidence of NV, these studies differ from this study's statistically significant findings that suggested that the higher the ITM dose, the more request for antiemetics. Thus, the third hypothesis in this study was supported that postulated patients receiving low-dose ITM would experience less NV than patients receiving higher doses of ITM.

Intrathecal morphine sulfate produces excellent postoperative analgesia. Unfortunately, because of its low lipid solubility, ITM has a slow rate of uptake in the spinal cord and tends to linger in the CSF (Markowsky, 1990). This study did not find any statistical significance between the ITM dose and patient requests for opioids within 24 hr postoperative TKA. A double-blind, randomized study by Girgin et al. (2008) suggested that patients who received ITM 0.1 mg provided analgesia comparable with ITM doses as high as 0.5 mg. Thus, the second hypothesis in this study was supported that postulated that there would be no difference in patient requests for opioids in the first 24 hr postoperative TKA between patients receiving ITM who utilized a low-dose ITM (0.1-0.3 mg) and patients receiving a high-dose ITM (0.4-0.5 mg).

This study also found that there were no differences in patient request for postoperative opioids with or without periarticular analgesia. This finding was not supported in the research literature. In a prospective, blinded, randomized study, Busch et al. (2006) found that patients who received periarticular multimodal drug infiltration used significantly lower requests for PCA over the first 24 hr after surgery than the patients who had received no periarticular infiltration. In addition, a double-blind study of 40 patients undergoing unicompartmental knee arthroplasty, Essving et al. (2009) found that periarticular infiltration of analgesia led to lower consumptions of postoperative opioids and increased range of motion, which resulted in decreased LOS. These disparate findings may be related to differences in research designs and sample size; thus, further research is warranted.

The most intriguing finding was that no significant relationship was found between the ITM group and the ITM group with wound catheter, and patient request for postoperative opioids. A wound catheter, which provides continuous infusion of local anesthetic, offers the potential to provide substantial anesthesia, decrease immediate postoperative opioid use, and can be used for several days (Liu et al., 2006). Liu and colleagues performed a meta-analysis that encompassed 44 different randomized clinical trials that included 2,141 patients across a wide range of surgical procedures and found that continuous wound catheters improved analgesia, reduced opioid use and its side effects, increased patient satisfaction, and reduced LOS. In a blinded study, 20 patients undergoing elective primary TKA, Pulido, Colwell, Hoenecke, and Morris (2002) found that patients who had continuous extracapsular infusion of local anesthetic had 35% less opioid consumption. In a randomized clinical trial of 80 elective total hip arthroplasty patients, Andersen, Pfeiffer-Jensen, Haraldsted, and Soballe (2007) found that patients who had continuous intra-articular infusion of local anesthetic were associated with a significantly reduced consumption of opioids, reduced LOS, and early ambulation. Placement of catheter either extracapsular or intracapsular may have affected patient pain levels; thus, further research regarding the placement of wound catheter may be warranted. Hence, findings from this study did not support the fourth hypothesis that postulated that the use of an extracapsular wound catheter to allow for continuous infusion of bupivacaine would request less opioids in the first 24 hr postoperative TKA than patients who did not have a wound catheter.

Even though the use of FNBs has been advocated to decrease opioid use and to provide adequate analgesia after a TKA (De Ruyter et al., 2006), the only significant findings between all three groups (ITM, ITM with FNB, and ITM with wound catheter) and the group that had ITM with FNB, and wound catheter was unexpected. In a prospective, randomized, double-blind, placebo-controlled study, Allen et al. (1998) found that an FNB was a useful analgesic adjunct for the immediate postoperative period after unilateral knee arthroplasty. A retrospective patient record study by Duarte et al. (2006) suggested that patients who received an FNB had significantly less pain than patients who did not have an FNB. Lastly, in a prospective, randomized, two-parallel-group study of 34 patients undergoing one-sided TKA, Ozen et al. (2006) found that the single-shot FNB led to a significant decrease in postoperative morphine consumption and was associated with fewer opioid side effects. These studies highlight that patients who had a knee arthroplasty with FNB anesthesia had better pain control and fewer opioid side effects than patients who did not have an FNB. This study, however, found that patients who received all three anesthetic modalities (ITM, FNB, and wound catheter) had better pain control and requested less opioids than the patients who had only ITM and one additional anesthetic modality (FNB or wound catheter), thus rejecting the first hypothesis.

Limitations

The concept of multimodal analgesia was introduced more than a decade ago to improve postoperative analgesia and decrease postoperative opioid use and its side effects (Reuben & Buvanendran, 2007). Pain after a TKA can be severe and, when inadequately controlled, can decrease the effectiveness of rehabilitation with physiologic, psychologic, and economical consequences (Sawyer, 2004). Because there are multiple approaches to postoperative pain management, it is essential that healthcare practitioners choose the type that will provide optimal pain relief. It is also important for patients and their families to be educated on postoperative side effects related to ITM. This retrospective chart review highlighted that patients who received all three anesthetic modalities (ITM, FNB, and wound catheter) had better pain control and requested less opioids than the patients who had only ITM and one additional anesthetic modality (FNB or wound catheter). Several benefits were noted when a lower dose of ITM was used for postoperative analgesia. For example, no differences were found in the number of requests for opioids in the first 24 hours postoperative between the low-dose and high-dose ITM groups. In addition, even though postoperative NV was a common side effect associated with ITM, the relative risk for NV was lower with the patients who received a lower dose. Despite these benefits, patient complaints of pruritus and the occurrence of hypotension were frequent, and these side effects were found not to be related to the ITM dose. Nevertheless, regardless of what type of anesthetic used, the nurse remains the key link in the assessment, administration of interventions, and the evaluation of the impact of pain interventions among patients (Pellino et al., 2005). Additional research using randomized trials is suggested to establish the significance of using multimodal anesthesia such as, ITM, FNP, and wound catheter, over other anesthesia for postoperative TKA pain management.

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