Thinking about Pain

It is now Saturday, the 5th day after surgery.  I am well past what conventionally has been the time period where most patients and surgeons feel is the most pain.  I now have minor discomfort only.  To discuss the pain and the specific ways my pain was managed by me and my surgeon I put together the following videos answering some questions about this topic:

Question: Can you comment on the observation that total knee replacement is often a high opioid use operation and yours was not?

Answer (transcribed):

In my experience as a surgeon for many years, total knee replacement has been an operation where we used quite a lot of opioids. Mine was not, and a lot has to do with the adoption of a lot of modern techniques. Specifically techniques that not only I have included in my own practice, but are adopted by my surgeon. These include the following: multi-modal pain techniques is very important. This includes intravenous Tylenol on a particular protocol, use of injections in the operating room with liposomal bupivacaine called Exparel. It also includes ice therapy. It includes early mobilization. It includes use of Tylenol around the clock and the use of anti-inflammatory medications pre-op and immediately postop.

With that regimen, since last Monday, I’m now at Friday, I took a total of 30 milligrams of oxycodone, three separate times I took 10 milligrams of oxycodone since Monday. That’s Tuesday, Wednesday, Thursday, Friday, over four days, just three minor adjustments with the oxycodone and no other opioids. I really attribute it to the multi-modal, and also to the expectations and trust that I had that the pain would be not as great as I might have expected.

Question: What day was the most pain, how was that pain, and how did you manage it?

Answer (transcribed):

I had the surgery on Monday. The most pain was probably Tuesday afternoon to late Tuesday evening. That was a time where I think the standard bupivacaine was wearing off and the Exparel was kicking in what is called a bridging time. The pain drifted to about 4 or 5 out of 10, never more than that, and then by Wednesday morning that pain diminished to about a 3 as the Exparel started working its full impact, so that was the most pain and it was quite manageable using the multimodal techniques.

Question: If during the time that you had pain, someone gave you any pill for the pain, would you take it?

Answer (transcribed): Well, interpret that question to me, and if I was in a hospital and I was just sitting there and I told a nurse or a doctor that I was in pain and they gave me a pill, would I question what pill they were giving me? I think most patients don’t, which is why we get into protocols.

It’s very common that many hospitals to give 2 Percocet, which is 20 milligrams of oxycodone every 4 to 6 hours. Some hospitals give 30 milligrams of oxycodone twice a day in addition to that. We have been stuck in the rut of a particular way that we have been ordering opioids, and I have found in my own experience that I was able to use significantly lower amounts of pain medicines as I mentioned, three 10 milligram doses of opioids over greater than 4 days. I think the pills that we give the patients need to be a much lower dosage and much wider separated apart, and we also need to adopt a multilevel pain regimen with the IV, Tylenol (Ofirmev) and with the Exparel, which is liposomal bupivacaine, which lasts in the knee 24 to 72 hours, sure.

Question: You are aware of some controversies in the literature about the effectiveness of different intraarticular injections.  You as a doctor know the pharmacology of these drugs. What is your opinion now that you have experienced this first hand as well as in your own practice about the use of plain bupivacaine and/or the addition of enhanced bupivacaine with liposomal bupivacaine called Exparel?

Answer (transcribed): I have used standard bupivacaine and, separately, standard bupivacaine with Exparel in my own practice, and I have seen an absolute improvement in the patient’s pain on the second and third days from the use of Exparel. Whether or not that decreased the length of stay is hard to say because we have a very early length of stay in my hospital. We average around two days anyway. I was done as an outpatient, so length of stay is not my endpoint, but rather patient satisfaction and patient satisfaction from pain relief, which was significantly better with the Exparel.

Personally, I experienced it. I saw the bupivacaine wear off at about 11 o’clock at night on Monday. I had a short amount of time of discomfort until the Exparel kicked in, which it definitely did because I had significant pain relief most of Tuesday where I did a fair amount of exercise, so Tuesday night my knee was sore, but the Exparel continued to work and Wednesday I had pain between 1 and 3, so that could only really be explained by the use of Exparel that severely limited my use of opioids in the first couple of days, as well as prevented any dependency I might have had to reach for a pill for the pain.

I took my bandage off and looked at the wound for the first time.


3 Comments Add yours

  1. Jason Neyman says:

    Hi Dr. K, I greatly appreciate your taking the time to share this journey. It will be helpful in many ways and to many people. I was the surgical tech on your knee replacement. I appreciated being able to see what our patients go through before and after as well as the proof of concept that the MIS and Multimodal techniques we practice in surgery have such a positive impact on outcomes. Thanks Ira, I’ll keep checking for your next post.


  2. Don St Peter says:

    Thank you for sharing your experience with us. Unfortunately yours, I believe, is a “unique” case in that you knew and had available to you, all this before hand knowledge and position. I want to share with you, and those out there, what is happening in the real world of knee replacement surgery by telling my story which I feel more represents the vast majority of cases. I will end my story with a couple of questions to you that may help the legions of us out there better understand the facts when facing similar or same situations.
    To set the stage, I live in a retirement community in Fl of over 100,000 people served by three major hospital systems and many different doctors. Of these three systems only one will allow Experal in their pharmacy for use, and then only by special request of persistent doctors that must be specially trained. (unfortunately this Dr. was not a choice for me). I must deduce this decision was made on a increased cost basis to the hospital. Perhaps there are other reasons not known to lay persons.
    After 3 days in hospital at pain level 7 to 8 and one week in in-patient Rehab Center, at pain level 7, and 5 weeks in out-patient rehab at what is now pain level 3 to 4 and my second prescription of 60 325 mg of Percocet; I find myself over the larger hill, but still struggling to get the 100 degrees you had in a couple of days without a lot of pain meds. Now my questions are:
    1. Why are the vast numbers of users of the health care system kept from utilizing current advances and technology by not making these products known and available to us the users?
    2. Are we, the users, supposed to communicate to the hospitals and doctors the false economics being used by considering the couple of hundred $$ up front cost of such meds and discounting the overwhelming costs of longer hospital stays, Rehab, loss of productivity, etc? If not who is?
    3. Lastly, and more importantly, are not the medical, doctor, and other health care communities playing a very large part in getting a handle on the pain meds and opioids overdose problems in the US? If not why not? Who will assume solving this vast and growing problem?

    For added information in a small part of our community I am aware that about 1/10 of total residents participate in an unused drug turn in program. Last quarter 1, 217 pound of drugs were collected by the sheriff’s department in this part alone. Also, before I left the 65 bed rehab facility, I ask the director how unused meds were disposed of. She said she had no idea and did not consider it their problem. I am following up on that one.
    Thanks again


  3. Linda Allan says:

    Hello, I just had knee surgery on August 16th 2016 — Dr. McAllister in Kirkland operated on my left knee. I couldn’t have more of a better doctor to do my knee.

    What really help was the Swift Path booklet helped so much it is about 40 pages and from page 1 to the end tells you what to do — with preparing for the operation– what you are going to need — what meds you have to get — when you have that information right in front of you, it just gives you so much peace. When my day came to get the operation I knew exactly what was going to happen — but most of all– everything at home was there waiting for me — the book told you even how to organize your house – to remove rugs- setup your bathroom– and to make a path to your bed !!

    After the knee operation I was able to walk to the bathroom and back to my bed — about the 2nd day the pain started but I can say it wasn’t as bad as I thought it was going to be. Sleeping was hard mostly because you couldn’t move around.

    In about 7 days I was walking almost without a walker – in about 2 weeks I could walk in my house without a walker – but outside I used a walker . In 2 1/2 weeks my walking got so much better and now in 3 weeks I am walking on my own…

    In 1 1/2 weeks I had 90 % range in my leg but I started exercising and stretching in bed from day one started slow, and I know that helped me the most, even if it was hard I knew I had to get my knee to stretch out !!

    Thank you Linda .


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