• Reducing Pain Scores and Opioid Consumption After Total Knee & Hip Arthroplasty:  A Ketamine Infusion Protocol

    Author(s): Maggie, Ludwig, RN, BSN & Alex Webster, RN, BSN School of Nursing, University of Minnesota, Minneapolis, MN

    Opioids are frequently used to manage perioperative pain associated with TKA/THA despite being associated with negative sequalae.


    Background

    • Total knee arthroplasty (TKA), and total hip arthroplasty (THA) are associated with moderate to severe, pain scores which can affect postoperative rehabilitation and patient satisfaction [1-2]
    • Opioids are frequently used to manage perioperative pain associated with TKA/THA despite being associated with negative sequalae (e.g. nausea, respiratory depression, urinary retention, and constipation). [1-2]
    • Multimodal pain relief regimens with non-opioid analgesics such as ketamine show superior pain relief and reduced opioid consumption after TKA/THA [1-2]

     

    Project Aim

    • lmplement an evidence-based interoperative ketamine infusion protocol for Certified Registered Nurse Anesthetists (CRNAs) to reduce intraoperative and postoperative opioid and administration as well as postoperative pain scores in TKA/THA patients.

     

    Methods

    • Setting: Small community hospital in rural Minnesota.
    • Project team developed ketamine infusion protocol after a literature review.
    • QI project deemed IRB exempt
    • CRNAs, Post-anesthesia Care Unit (PACU) and med-surg RNs received education about protocol via PowerPoint presentation and information packets.
    • CRNAs added ketamine infusion order to preop order set for TKA/THA patients.
    • Coordinated with pharmacy to make pre-filled 2 mg/mL ketamine syringes for each patient with order.

    Ketamine Infusion Protocol

    1. Verify patient is appropriate candidate for ketamine and consider lower dose for age >75.
    2. Ketamine bolus 0.25 mg/kg ideal body weight (IBW) after sedation initiation and prior to incision.
    3. Start ketamine infusion at 2.5 mcg/kg/min (IBW).
    4. Stop infusion 15 minutes prior to emergence.

    Measures

    • Average intraoperative fentanyl administration
    • Average total PO morphine equivalents administered in PACU
    • Average total PO morphine equivalents administered 24 hours postoperatively
    • Average pain scores in PACU
    • Average pain scores 24 hours postoperatively

     

    Data Analysis

    • Data collected via chart review during three month implementation period and compared to same three month period one year prior.

     

    Results/Discussion

    • Decrease in average reported pain scores in PACU for TKA and 24 hours post-op for both TKA/THA after protocol implementation (Figure 1).
    • Decrease in average PO morphine equivalents administered in PACU for TKA and 24 hours post-op for both TKA/THA after protocol implementation (Figure 2).
    • Minimal decrease in intraoperative fentanyl use for TKA/THA
    • Barriers to CRNA adoption of protocol included lack of infusion pumps and difficulty properly wasting large ketamine syringe.
    • Project was implemented in the context of the COVID-19 pandemic.

    References and original poster.

    Ketamine poster fig. 2

     

     

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