I am currently on a waitlist for a total knee replacement (TKR) and have been diagnosed with paroxysmal atrial flutter/atrial fibrillation (AF/AFL). Before the surgery, I plan to have an in-depth conversation with the anesthesiologist regarding the strong pain medications (opioids) typically prescribed for the first few days/weeks following TKR surgery.
The medication I currently take to control my atrial flutter is diltiazem (extended-release), and I also take apixaban to reduce the risk of stroke. I understand that diltiazem inhibits the CYP3A4 enzyme, which metabolizes many opioids. This interaction could potentially increase the levels of opioids in my system, raising my concerns about respiratory depression. Additionally, NSAIDs are not an option due to the bleeding risk associated with apixaban, leaving acetaminophen/Tylenol (paracetamol) as the only alternative. I am aware that a nerve block is typically applied during the operation, but I am particularly concerned about pain management returning home.
My question is: Has anyone with AF/AFL who is on a calcium channel blocker (or even a beta blocker) been through any type of surgery which required opioids or any other strong medication for pain afterward? How did you manage with side effects and your AF meds yet still somewhat control the pain while recovering? Or what did you find was most effective?
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FraserB
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I'm sure your anaesthetist will be well versed in the interactions of the various drugs.
I had THR whilst taking occasional Bisoprolol plus other heart meds. No problem with Codeine or Morphine. In fact I was on Morphine patches in the preceding months.
That's good to know about your ability to take both Codeine and Morphine. I'm in Canada and I was told I can speak with the anesthesiologist a few weeks before the surgery. The wait times here are long but I will be grateful to have it eventually done. Just worried that I don't end up a "zombie" on the pain meds interactions.
You certainly won't be rushing about any time soon after your procedure so if there is an interaction you just rest up and cut back your dosage. One of the advantages of spinal anaesthesia is that the pain relief is dealt with more efficiently so that you will ' come to' more comfortably.
I had a partial knee replacement in November 2015 (aged 71) under general anesthetic, and whilst it wasn't a walk in the park, if you do what your told it's an OKay deal. My party bag of drugs at this time was Warfarin, Bisoprolol, Ramipril and Felodopine.
I was told to discontinue Warfarin 6 days prior to Surgery in order to get my INR back to 1 or as close to it as possible ... no sweat. All other meds I continued. After surgery when I was back in my room nurses gave me two injections of a bridging anticoagulant ( Fragmin ) into my belly area and that night I returned to my normal dose of Warfarin ... no sweat.
Pain was the biggest deal for me and liquid morphine did nothing for me. I just continued with CoCodomol 30/500 ( prescription grade here in UK ) I started this prior to surgery to help me cope with pre op pain. I continued it after surgery with post op pain. I return home 3 days after surgery and dressings were removed at 21 days. The Cocodomol helped massively with coping with the exercises over the following 8 weeks or so. I was back at work bus driving at 11 weeks. Would have been 8 or 9 weeks but Christmas 2015 fell in my recovery period and my surgeon was away.
Warfarin was the determinant for pain relief and the CoCodomol did the job. It enabled me to cope with the post op exercises which you must do if you ever wanna walk properly again. I had no side effects from CoCodomol.
These days I still use Cocodomol but nowadays for osteoarthritic shoulder pain relief. No problems with the knee, except, if the cat puts one of her cat toys under furniture kneeling to retrieve it is hard work ( even 9 years down the track) as the knee is quite stiff and tight ... but no pain.
Hope all that helps. Oh yeah ... in all this process AF never ever reared its ugly mug, nor did palpitations return.
I've heard that the first couple of months can be quite challenging when it comes to regaining mobility. Thank you for sharing your experience with liquid morphine. It sounds like the Co-codamol 30/500 will be essential for getting through the post-surgery exercises. Everyone I’ve spoken to who has had TKR surgery says if they could give only one piece of advice, it would be to follow the exercises as instructed. However, none of them also had AF or AFL on top of it, so I really appreciate you mentioning that your AF stayed away during that time. That’s a major concern for me as well.
Reading WhitstableWanderers post reminded me ................. after the dressing was removed in addition to my regular exercises I attend my Sports Injury Massage Therapist for weekly deep massage around the scar area ........ just as WhitstableWanderer says ... see below :
"And, because the scar tissue around the knee stiffens up in the first few weeks, you HAVE to get the knee moving and extended, otherwise it'll all sieze up and further unpleasant intervention will be necessary".
It is vital that scar tissue doesn't get a grip, ongoing exercises will be virtually impossible after that if it does - not forgetting further intervention which will be an unwelcome setback.
Yes, I had a hip replacement, Co-codomol or Paracetamol advised taken without problems, also Morphine. Prior to surgery you should see the Anaesthetist and go through everything with them. Good luck with the surgery and a swift recovery , look forward to being pain free!
I had a TKR 6 weeks ago, and have mostly asymptomatic AF, no flutter. My usual meds are just Riveroxaban anticoagulant, which I was advised to stop 48 hours before the knee op. It felt odd not to take the little red pill that I've taken every day for over five years but no noticeable side effects were experienced. I was given a spinal anesthetic for the op and declined anything else so I could stay awake, which makes for a quicker recovery post op. The op took about 90 minutes, and the spinal anesthetic lasted around 12 hours, so initial pain not an issue. They kept me in hospital overnight, went through the required physio the next day and was released, with a few days supply of oxycodone hydrochloride, a very strong opiod pain killer, plus a further 14 days supply of codeine phosphate, also an opiod but not as strong.
Generally, I dislike having to take pills of any type but quickly realised that the pain killers are absolutely essential post TKR. For one, the ongoing discomfort is genuine agony, and secondly, to even attempt the required physio exercises, you need to manage the pain. And, because the scar tissue around the knee stiffens up in the first few weeks, you HAVE to get the knee moving and extended, otherwise it'll all sieze up and further unpleasant intervention will be necessary. As the hospital physio made clear, undergoing the exercises and considerable pain in the early weeks really saves a lot worse and lengthy pain in the future.
At six weeks, I can walk without crutches though maybe only 20 - 30 minutes at a time as I build strength back up, and I can now drive again.
So, as you approach your TKR, do not underestimate the need to manage the post op pain for at least a few weeks (I am still taking a couple of codeine daily to help with this), and, especially in the first two or three weeks, do the required exercises and physio supported by strong pain killers - you won't be able to do these without some form of pain relief. Good luck, hopefully in six to twelve months time, we will be able to look back and be pleased we went through all this. Then, for me at least, the other knee will need doing!
on list for right TKR had left done 6 years ago, However, didn’t have AF then and could take anti inflammatory meds. Agree with everything you say re pain control essential. I had general anaesthetic then but want spinal this time. You’ve really helped me. Sorry this reply doesn’t answer FraserB’s initial post but so grateful to read your experiences. Take care 🦊x
Appreciate reading your experience and I will also be stopping the apixaban before the surgery but still need to take the diltiazem. When I speak with the anesthesiologist I will be certain it's a spinal because diltiazem already makes me drowsy, I couldn't imagine adding general anesthesia to the mix. Your reply about not underestimating the needs to manage the post op pain I agree with completely. I definitely don't want the doctor to think because I'm on AF meds that maybe it's best not give me the strongest pain relievers right after surgery. The goal is to get the knee moving no matter how difficult.
A question for you; with your spinal did you hear everything that went on? I'm asking because the last thing I need is for me having an adrenaline surge which doesn't work when you have AF combined with surgery.
Hi Fraser, it's interesting that you've asked about me hearing everything during the knee op - yes, I did! Various friends were horrified that I didn't request any anesthetic other than the spinal, but I understood that recovery would take a little longer if I had. In any case, I found the procedure fascinating... I could hear the sawing, drilling and hammering but couldn't feel a thing..... they put a sheet up as a screen so I couldn't see anything though. Something that I didn't mention in my earlier answer, was the need to ice the knee regularly. I'd recommend purchasing an EverCryo or similar device, much easier than a bag of peas.
Good heavens!😱 When I had my hip replacement 2 years ago I had spinal anaesthesia but stipulated that I didn't want to hear any sawing or hammering! I wanted to be completely sedated and I was. I never heard or was aware of anything going on.
I woke up feeling pretty good as of course the spinal block allows plenty of painkillers to be pumped into you to tide you over.
Thanks Joy for describing your types of pain meds and how they titrated the different strengths as the days went on with your surgery and interesting to read that your also on diltiazem.
Very important to separate CCHs and BBs NZ Heart Nurse pointed out.
My private heart specialist put me on Diltiazem. It reads and is proven that Diltiazem is better by symptoms than its comparison Vermapril.
I've been on it 120mg since December 2021. It had a huge effect on bringing down my rapid heart rate. BP not much and that is why at PM I take Bisoprolol 2.5mg.
I'm learning all the time and I love it.
All the best for your knee replacement. I had 2 MRIs back in 2013 and 2016. Same but knee swollen out to side. Under our ACC I asked surgeon to get in and look. Apart from a few small tears, this other not showing on MRIs, in the meniscus was so bad he had to cut it out.
Still no more continuous pain just some when I carry heavy items or put my other knee over or it be too many blankets.
At least I've stlll retained my natural knee. Stable yes.
You take care and no driving on some of the pain meds. Just watch for infection eh!
I'm also on the same dose of diltiazem as yourself and do find it effective for my flutter though doctor says this may change up in future. For now diltiazem controls the ventricular rate when I'm in atrial flutter also does not affect my liver metabolism. Good to read your knee is stable especially with your meniscus problem, nothing worse when it acts up.
When I had my TKR I had not been diagnosed with AF (although unbeknownst to me it was just beginning to get going! )Therefore I did not have a bag of tablets to take in with me.
The reason I am replying is re post surgery meds … When I came round from the op I was hooked up to what I presume was a self administer morphine pump. I didn’t need it. After several hours the nurse registered that I hadn’t used it and removed it. I just had paracetamol (and the Fragmin injection). I was not in pain. Once home and moving about, my knee did ache occasionally at night. I was prescribed co dydramol, which I used now and again. The golden rule of TKR pain relief ‘Ice is your best friend!!’
Good luck with the replacement, follow instructions, ice, elevate and do the exercises!
Thanks for describing your pain meds and especially their affect. And I agree that ice is your best friend. Since I cannot take NSAIDS because of the interaction with my AF meds I need to be "armed" with other ways to get swelling and inflammation down so I'll be renting a cold therapy machine plus have bags of ice ready.
Unfortunately I have what my orthopaedic surgeon has medically described as severe varus deformity which goes with some forms of advanced knee osteoarthritis. Fifteen years ago I had a traumatic fall that fortunately left me still walking. Over years two bones have shifted dramatically in the opposite directions leaving me now dependent on a cane all the time since I can fall over easily, and I have (also not safe when you're on a DOAC). Doctor said a walker would be safer, but I'm otherwise (besides the AF) healthy. And of course sharp pain is now starting to set in.
Nope - hand on heart, just as I described it. Paracetamol was enough - and this is from someone who always found aspirin to be the best pain relief!
Discomfort - yes, but not pain.
My surgeon has a thing for hydrotherapy so I was in the pool 24 hrs after my op. Daily during my hospital stay and regularly afterwards. Perhaps that helped?
But you are right, I do seem to have quite a high pain threshold.
You're correct about that.... the diltiazem I take for my AFl already causes it. Add on any pain medication and I'll need lots of water and the best of laxatives. When it's all said and done this could easily end up the biggest concern.
Thanks Joy for letting me know about cheese. I do like it but will avoid while on the mend after surgery. We worry about AF and our hearts, but when it comes to constipation I think we know what probably rules the body more.....😀
Problem can become an obstruction in colon or bowel and it could become diaster - surgery.
To make me a more attentive energetic person daily ablution is a must. And don't ever let a nurse put the suppository further up to the top of impaction. Just inside please.
Beyond does work for me.
Drink plenty of water too.
2 Brazil nuts give you selemium T3 for the thyroid.
After drink water and thyroid pills early morning for me. I was encouraged to get an stool as we sit wrongly!
I'm hedging you will breeze through the operation with a new lease of life especially with all the preparation and focus.
Will it be stainless steel or titanium?
The walking robot.
Every MRI they should ask you where all the metal is?
I had a hip replacement a couple of years ago. I have AF and on Apixaban and Bisoprolol. I had a spinal block and enough sedation that I knew nothing of the op. Afterwards I was on everything going for pain relief - paracetamol, dihydrocodeine and Iboprufen, with Omeprazole to protect my tum. When you go for your pre-op assessment the nurse will have your full medical history and the anaesthetist will be fully appraised of your situation. Try not to be too anxious- you’ll be fine. To be pain free and mobile again is marvellous. Best wishes.
Thanks so much for sharing your experience and the medications. Definitely the spinal for me too. I keep forgetting it's a team of medical people involved and I'm certain they've probably seen many others with similar or the same health conditions. The next step my doctor said is a walker that's how severe my knee arthritis has become. Hearing that I'll keep my sights set on, as you've mentioned, being mobile and pain free again.
I’m waiting for tkr x2, the first was due 2 years ago but went into af on the morning so cancelled, I’m now just starting the whole process again. I’m also concerned re pain relief, as I’m unable to take NSAID and when given opioid after my hybrid minimaze I had an adverse reaction to that. I’m allergic to aspirin. I have taken co codamol but only the 8/500 as stronger sends me doolally. Think I’m going to be a challenge for them re pain relief. I’m hopeful that ice works as well as everyone suggests as does medication and mindfulness
Sorry to read you went into AF in the morning of your TKR, that is also on my mind. I also can't take NSAIDs because of my meds. I sometimes think that those without AF who get TKR are correct when they say the first weeks of pain are unbelievable but they don't have any idea what adding on a potential fast erratic, non-stop heartbeat feels when you can't even get your breath.
I'm already planning on the ice therapy and your mention of mindfulness is I believe another effective tool. It can help reduce AF anxiety and the heart rate. And is worth taking that time each day to practice even if only for 5 minutes. How our minds work carries more weight in any AF diagnosis and is understudied by traditional medicine.
I have had both hips replaced. I do not take Diltiazem but I do have problems with all painkillers. I think I must metabolise slowly naturally as the effect lasts far longer than the nurses seemed to think it should. I was prescribed both Paracetamol and Tramadol and took the absolute minimum alternating days for each one. I stopped completely after 10 days. What I did find useful was my surgeon's insistence that all hjs patients continually ice the area operated on. In the clinic they had soft rubber bags of ice cubes that were continually renewed and at home I used a sports gel pad wrapped in a tea towel.
Yes - same for me re continual icing. My surgeon requested all his patients buy a ‘bucket and cuff’ - (controlled cryotherapy) for this purpose.
At home, husband was in charge of filling the ice bucket - and what a lot we got through! Thank heavens for grocery delivery, After a short while I found ziplock bags of ice and a tea towel were a quicker way to do the job. However, the benefit of the bucket/cuff system is that you can easily ice in bed /asleep.
Your description of prescribed medications is probably what I will be looking at as well. Even with AF and based on others responses some surgery pain can be severe and requires meds like Tramadol along of course with the Paracetamol but keeping as best as possible to a minimum because I too react not very well to any form of pain reliever even before I was diagnosed with AFL. And ice therapy is definitely important.
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