Effectiveness of a multimodal analgesia protocol in the perioperative period of knee replacement surgery in men

2.1 General information

A cohort of 80 male patients scheduled for artificial knee replacement surgery at the Department of Orthopedics, West China Hospital of Sichuan University, from March 2022 to March 2023, was enrolled and allocated into two groups through digital randomization: 40 participants in the control group and 40 in the observation group. The observation group received a multimodal pre-analgesia protocol comprising patient-controlled analgesia (PCA), ultrasound-guided nerve block, and physical analgesia, whereas the control group was subjected to a conventional analgesic protocol.

Participants were eligible for inclusion in the study if they were aged 18 years or older, classified as American Society of Anesthesiologists (ASA) grade I to II, diagnosed with unilateral knee joint disease, met the criteria for artificial total knee replacement surgery with an elective approach for minimally invasive surgery, and provided informed consent from themselves and their families. Exclusion criteria comprised individuals with impaired consciousness or mental disorders, those suffering from severe organ failure or advanced tumors, and cases involving open fractures.

The mean age in the control group was 75.02 ± 4.30 years, and in the observation group, it was 75.13 ± 4.26 years. Statistical analysis revealed no significant difference in the baseline data between the two patient groups (p > 0.05).

2.2 Research methods

2.2.2 Research methods of the observation group (Fig. 1)

Fig. 1.Technology roadmap Annotate. PCA: patient-controlled analgesia; VAS: Visual Analog Scale.

The observation group received a multimodal analgesic nursing intervention, detailed as follows:

Preoperative preparation (over-the-counter analgesia):

(a) Patient Education: Nurses actively communicated with patients and their families 1 to 2 days before surgery, emphasizing the importance of pain management and setting expectations for postoperative pain and analgesic methods. This included the expectation of postoperative pain and the feasibility of analgesic methods.

(b) Emotional support: Nurses provided emotional support by addressing patients’ concerns, offering comfort, and alleviating preoperative stress.

(c) Preoperative Analgesic Drugs: Based on medical prescriptions, preoperative analgesics were administered to minimize discomfort before surgery.

Postoperative management (analgesic drug care):

(a) Epidural analgesia pump: The anesthetic regimen for the epidural analgesic pump was tailored to complement the anesthetic drugs utilized during the patient’s surgery. This pump, typically used for a continuous duration of 48 hours post-surgery, is important in maintaining consistent and effective pain management throughout the early recovery phase.

(b) Medication adjustment: Analgesic dosages were tailored to the patient’s pain levels and needs, with adjustments made as necessary. Intravenous infusion of non-steroidal anti-inflammatory medications was utilized to enhance analgesia when required.

Hierarchical analgesic nursing:

(a) Pain assessment: Visual Analog Scale (VAS) was used for regular assessment of patients’ postoperative pain at 3–6 hours intervals. Following each evaluation, three successive measurements were conducted within 30 min, and the average of these scores was documented to ensure accurate pain assessment.

(b) Analgesic strategy: Strategies were devised based on VAS scores, with non-pharmacological methods prioritized for scores below 3. For scores of 3 to 6, a combination of non-pharmacologic and moderate pharmacologic analgesia was used, and for scores above 6, pharmacologic analgesia was recommended.

Non-pharmacological analgesia:

(a) Music therapy: The pleasurable effects of music were used to create a serene environment for patients to improve psychological comfort and promote a sense of well-being.

(b) Emotional support: Nurses provided emotional support to patients to enhance their psychological resilience and help them in managing the stress associated with post-surgical recovery.

(c) Family affectionate support: Family support was provided to enhance the patient’s confidence in the treatment process, effectively reducing sensations of pain and establishing a conducive atmosphere for recovery.

(d) Early activity and muscle relaxation method: Patients were encouraged to initiate early rehabilitation activities and muscle training to maintain joint mobility and prevent venous thrombosis. Meditation and relaxation techniques were also taught to reduce stress and tension.

Pain recording and management:

(a) Patient self-assessment: Patients were advised to perform self-assessments at 1 to 2-hour intervals for a more accurate understanding of their condition. Additionally, keeping a pain diary was encouraged, wherein they documented the intensity, location, timing and other relevant aspects of their pain. This diary serves as a vital tool for the nursing staff to comprehend the patient’s pain status comprehensively, facilitating timely adjustments to the treatment plan tailored to meet the patient’s specific needs.

(b) Regular assessment: Nurses regularly reviewed the patient’s pain diaries and discussed any changes in their pain experiences. Utilizing the insights gained from the diaries, the nursing team made adjustments to medication dosages and non-pharmacological analgesic approaches or offered additional support to ensure effective pain management for each patient.

Regular review and adjustment:

(a) Adjustment of the care plan: The patient’s care plan was continuously evaluated and refined. As the patient recovered and exhibited varying responses to pain management, the nursing team dynamically adapted the analgesic protocol, tailoring it to address the unique needs and circumstances of the patient.

(b) Teamwork: The medical team, including anesthesiologists, surgeons, and pain management specialists, conducted regular consultations to develop and adjust treatment plans, ensuring optimal pain management for patients.

(c) Ongoing patient education: Patients and their families received ongoing information and guidance on pain control, enhancing their understanding of treatment progress and the significance of pain management. This approach improved patient engagement in the treatment process.

2.3 Observation indexes

Observation indices for this study included:

2.4 Statistical analysis

Data analysis was conducted using the SPSS v25.0 (IBM SPSS Statistics, IBM Corporation, Armonk, NY, USA). Measurement data following normal distribution are presented as mean ± standard deviation (x̄ ± s), while non-normally distributed data are presented as medians (M) with the 25th and 75th percentiles (P25, P75). Comparisons between the two groups were performed using the t-test for normally distributed data and the Mann-Whitney U-test for non-normally distributed data. To analyze differences across multiple time points within the groups, repeated-measures Analysis of Variance (ANOVA) was utilized. Categorical data were represented as frequencies (percentages) and analyzed using the Chi-square (χ²) test. Rank data comparisons were made using the rank-sum test. A p-value of less than 0.05 was considered to indicate a statistically significant difference.

3.1 Comparison of postoperative celecoxib capsule dose between the two groups

The dosage of celecoxib capsules administered postoperatively differed significantly between the two groups. In the control group, the dose was 200 mg, ranging from 0 to 400 mg, which was notably lower than the 400 mg dose, ranging from 0 to 800 mg, given to the observation group. This difference in dosage was statistically significant, as evidenced by the Mann-Whitney U test result (U = 453.674, p < 0.001).

3.2 Comparison of VAS scores between the two groups at different times during the postoperative period

Regarding the comparison of VAS scores at various postoperative times, significant differences were observed between the two groups. The analysis considered group differences, time points, and their interaction, with all showing statistically significant variances (p < 0.05), as detailed in Table 1. This finding suggests that the pain experiences of patients in the observation group and the control group varied significantly over time during the postoperative period.

3.3 Comparison of neurotransmitter levels and stress response indexes at different times after surgery between the two groups of patients

The analysis of neurotransmitter and stress level indicators between the two groups over various postoperative timepoints demonstrated statistically significant differences (p < 0.05), as presented in Table 2, underscoring the impact of the interventions on physiological stress and pain management outcomes.

3.4 Comparison of sleep quality scores and first-time out-of-bed activities between the two groups of patients

The observation group reported a lower sleep quality score compared to the control group, indicating better sleep quality. Additionally, the time taken for patients in the observation group to get out of bed for the first time post-surgery was significantly shorter than that of the control group, with the difference being statistically significant (p < 0.05, Table 3).

3.5 Comparison of the total incidence of postoperative complications between the two groups of patients

The total incidence of postoperative complications in the observation group was found to be significantly lower than in the control group, as detailed in Table 4 (p < 0.05).

4.1 Multimodal analgesic protocol can reduce patients’ postoperative pain level

The findings of this study reveal significant differences in VAS scores across groups, over time and in their interactions at various post-surgical intervals (p < 0.05). Notably, the dosage of celecoxib capsules in the observation group was less than that in the control group, suggesting that a multimodal analgesic approach not only enhances pain management, thereby reducing patients’ pain levels, but also decreases the necessity for non-steroidal anti-inflammatory drugs, limiting their potential adverse effects [11]. The initial assessment is important for developing a personalized analgesic plan, ensuring each patient receives a bespoke pain management strategy. This approach aims to alleviate pain effectively while also curtailing the risk of opioid dependency by judiciously increasing the use of celecoxib [12]. Patient-controlled analgesia (PCA) systems offer timely pain relief within a safe margin, empowering patients to manage their pain more actively. This autonomy in pain management helps lessen pain perception and diminishes the need for supplementary analgesics [13]. Gao et al.’s [14] findings aligned with our present study, demonstrating that ultrasound-guided nerve block techniques can pinpoint and block nerves more precisely. This precision reduces the amount of local anesthetic required and significantly alleviates postoperative pain, underscoring the efficacy of this study’s results. Overall, the combined effect of various drugs within a multimodal analgesic regimen culminates in superior pain control.

4.2 Multimodal pre-analgesic protocols can control serotonin levels and stress in patients

The multimodal analgesic regimen demonstrates enhanced effectiveness in managing patients’ neurotransmitter levels and stress responses when compared to traditional PCA [15]. Our study’s findings indicate that multimodal analgesia can significantly regulate serum neurotransmitter levels and diminish patients’ stress responses. The regimen utilizes a comprehensive approach for pain control, incorporating local anesthetics, analgesic medications, nerve blocks and physical methods of pain relief [16], thus offering a more pronounced impact on neurotransmitter levels and stress responses. According to Ochroch et al. [17], the diverse drugs and techniques employed in the multimodal protocol synergistically adjust neurotransmitter levels, such as lowering inflammatory mediator release and influencing β-EP and 5-HT levels, thereby reducing sensory pain and stress responses. This approach also exerts a greater inhibitory effect on stress indicators like Cor, CRP and WBC by reducing inflammatory responses and the release of inflammatory mediators, thus effectively minimizing neurotransmitter levels and stress responses [18]. Prasad et al. [19] further corroborate that a multimodal analgesic regimen provides more reliable and all-encompassing pain management through an array of mechanisms, reducing pain perception and likely resulting in a more stable modulation of neurotransmitter levels and stress responses, aligning with the findings of our present investigation.

4.3 Multimodal analgesic protocol can improve patients’ sleep quality and shorten patients’ first time out of bed

This present study demonstrated superior sleep quality and earlier “first-time out-of-bed” activities among patients in the observation group compared to the control group, with statistically significant differences (p < 0.05), indicating that the multimodal analgesic protocol by integrating various pain management strategies, more effectively reduces postoperative pain than conventional PCA approaches. The reduction in pain facilitates better sleep by decreasing nocturnal awakenings, thereby enhancing overall sleep quality [20]. The multimodal approach modulates neurotransmitters, such as lowering levels of β-EP, which has a positive impact on sleep, contributing to more restorative rest for patients [21]. In contrast, traditional pain management methods may rely more heavily on medications that can adversely affect sleep, including causing drowsiness or nightmares [22]. By utilizing a multimodal regimen, reliance on any single class of medication is reduced, minimizing potential side effects. Moreover, the multimodal analgesic protocol encourages early postoperative mobilization, which aids in quicker recovery, diminishes postoperative discomfort, and promotes acceptance of early ambulation activities. Early mobilization also enhances blood circulation, mitigates the risk of postoperative complications, and fosters better sleep patterns [23]. Through comprehensive pain management and the alleviation of postoperative stress and anxiety, the multimodal protocol substantially improves patients’ sleep quality [24]. Consequently, the multimodal analgesic protocol offers a more holistic and effective approach to postoperative care, encompassing pain control, neurotransmitter balance, reduced medication side effects, early physical recovery, and psychological well-being, leading to an improved sleep experience for patients [25].

4.4 Multimodal analgesic protocol can reduce the incidence of postoperative adverse reactions in patients

The results of this study showed that the observation group experienced fewer adverse reactions compared to the control group, with the difference being statistically significant (p < 0.05). This outcome can be attributed to the multimodal analgesic protocol, which incorporates various methods such as local anesthesia, analgesic drugs, and nerve blocks [26]. Through preoperative evaluation, the multimodal analgesic protocol enables the selection of suitable drugs and techniques tailored to the patient’s unique needs, thus minimizing the risk of allergic reactions or adverse responses to specific medications and facilitating more personalized care [27]. The application of local analgesic methods, like nerve blocks, diminishes the systemic distribution of drugs, reducing the potential for widespread adverse effects. By integrating diverse analgesic approaches, the multimodal protocol offers more comprehensive and consistent pain management while mitigating adverse events [26]. Furthermore, it supports quicker post-surgical recovery, lessens postoperative discomfort, and encourages prompt engagement in recovery activities [28]. Early mobilization enhances blood flow and lowers the risk of postoperative thrombosis, thus decreasing the likelihood of related adverse outcomes. Additionally, the multimodal protocol significantly improves patients’ psychological well-being by managing pain effectively, which in turn reduces anxiety, stress and the possibility of adverse reactions linked to psychological factors [29]. Overall, by leveraging multiple mechanisms to manage pain, the multimodal analgesic protocol effectively reduces the incidence of adverse effects, ensuring safer and more efficient pain management for patients.