Multimodal analgesia practices for knee and hip arthroplasties in the Netherlands. A prospective observational study from the PAIN OUT registry.

INTRODUCTION: Different multimodal pain management strategies following total hip arthroplasty(THA) and total knee arthroplasty (TKA) surgery are used in clinical practice. The optimal pain management strategy, however, remains unclear. This study aims to evaluate the differences in perioperative multimodal pain management strategies for THA and TKA in the Netherlands, and studies the associations between patient- and therapy related factors and pain outcomes. METHODS: Data from the Dutch hospitals in the PAIN OUT network were used in this study. Demographic data, pain management strategy including perioperative medication use and anesthetic techniques were recorded and used in a multivariable regression analysis to study the association with maximum pain intensity, the duration of severe pain, pain interference in bed and postoperative nausea. RESULTS: In 343 hip arthroplasty patients and 301 knee arthroplasty patients in seven hospitals, respectively 28 and 35 different combinations of analgesic regimens were used. The number of different drugs prescribed was not related to postoperative pain intensity. Female sex, younger age and spinal anesthesia were associated with higher postoperative maximum pain scores (Numeric Rating Scale (NRS) > 5). Hip surgery and ketamine use were associated with lower postoperative pain scores. The use of non-steroidal anti-inflammatory drugs (NSAIDs) and gabapentinoids, higher age, higher body mass index (BMI) and male gender were associated with less postoperative nausea (NRS < 3). CONCLUSION: In conclusion, our study demonstrated a large diversity of analgesic strategies following total joint arthroplasties in the Netherlands. Although no ideal strategy was identified, the use of NSAIDs, ketamine and dexamethasone were associated with less pain and less side effects.

Simulation at the Frontier of the Zone of Proximal Development: A Test in Acute Care for Inexperienced Learners.

PURPOSE: Vygotsky's zone of proximal development (ZPD) refers to the space between what learners have mastered and what they should master in the next developmental stage. Physicians' tasks are ZPD activities for medical students, with high-acuity tasks such as resuscitation representing activities at the ZPD's frontier. This type of task can be taught and assessed with simulation but may be demanding and stressful for students. Highly challenging simulation may lead to a negative simulated patient outcome and can affect the participant's emotional state, learning, and motivation. This study aimed to increase understanding of the psychosocial and educational impact of simulation at the frontier of the ZPD. METHOD: The authors conducted 11 phenomenological interviews between September 2016 and May 2017, to describe medical students' experiences with a challenging residency-level simulation test of acute care competence at the start of the final undergraduate year at University Medical Center Utrecht. Interviews took place within 2 weeks after the participants' simulation experience. The authors analyzed transcripts using a modified Van Kaam method. RESULTS: Students experienced a significant amount of stress fueled by uncertainty about medical management, deterioration of critically ill simulated patients, and disappointment about their performance. Stress manifested mainly mentally, impeding cognitive function. Students reported that awareness of the practice setting, anticipation of poor performance, the debriefing, a safe environment, and the prospect of training opportunities regulated their emotional responses to stress. These stress-regulating factors turned stressful simulation into a motivating educational experience. CONCLUSIONS: Simulation at the ZPD's frontier evoked stress and generated negative emotions. However, stress-regulating factors transformed this activity into a positive and motivating experience.