1. Evidence Based Analgesia for lower limb arthroplasty
EBPOM SATELITE MEETING
8TH JULY 2011
DR ROBERT STEPHENS
DR SARAH BARNETT
Whole talk at
Or Google ucl anaesthesia stephens

2. FACT 70% of patients report moderate to extreme post-operative pain
PROSPECT – procedure specific postoperative pain management, evidence based, managed and developed by anaesthetists and surgeons

3. How to think about this.. ‘Evidence based’ What do patients want?
What do surgeons want?
What do anaesthetists want?

4. Levels of Evidence
Oxford Centre for Evidence-based Medicine:
From Owww.cebm.net

5. A B C D

6. Problems Small studies- poor power, less than ideal design
Most studies 1 centre ie enthusiasts – not ‘real world’
Rubbish statistics eg ‘average pain score 2.2’ (1-5)
Many older studies eg pre USS techniques
Many studies use nerve catheters
Recent trend to ‘enhanced’ recovery – different techniques ? Speed ‘important’ vs ‘experience’
Studies looking at only 1 thing eg pain
Many anaesthetists rarely see postop consequences
Local infiltration gives control to surgeons / interest
Previously ‘our’ area

7. What do patients want? total hip arthroplasty (THA) or
Macario et al 2008
Patients consulting an orthopaedic surgeon about undergoing either
total hip arthroplasty (THA) or
total knee arthroplasty (TKA)
Rate the importance of different questions about their care.

8. What do patients want? Macario et al 2008
Assembled questions patients might have about joint replacement surgery
29 considering undergoing THA and
19 patients considering TKR
Completed written survey asking them to rate 30 different questions
5 point from 1 (least) to 5 (most important)
(Likert scale)

9. Patients' overall ranking (median scores) of the importance of addressing questions regarding joint replacement surgery
n= 29 19
Hip Knee
Will the surgery affect my abilities to care for myself? 5 5
Am I going to need physical therapy?
How mobile will I be after my surgery?
When will I be able to walk normally again?
What are my options if I decide not to receive surgery? 5 4
Will the surgery cause pain afterwards?
How long will I be in the hospital?
Is there anything I can do to eliminate pain after surgery?4 5
Will I receive medication to manage the pain? 4 4

10. How will I be able to manage severe pain? Tell me about my prosthesis?
Additional questions written in by the patients
How will I be able to manage severe pain?
Tell me about my prosthesis?
What is the surgeon's medical background?
Why should I have confidence in him?
Tell me about the surgery procedure
Am I seeing a film of the surgery?
What are my post surgical physical therapy options? (home/outpatient)
Whom do I ask about my medications for pain and inflammation?
How many of these procedures has my surgeon done?
What is the infection rate?
How long is the entire recovery period?
How much will the physical therapy after the surgery cost?
Will this surgery lead to constipation?
What is the average length of time I will need to recover my facilities?
Are there any problems I may face in full recovery?

11. What do surgeons want? Bio-psycho-social approach
Maintain muscle power
Minimise complications
Active patient involvement - education
Clinical pathways (Barbieri et al 2009)
Enhanced recovery (Kehlet et al 2008)
Avoid DVT
Good physiotherapy

12. What do anaesthetists want?
Good quality analgesia for patients
Regional techniques: Neuraxial block/Nerve block
Maintain skills
Provide good surgical field
Optimise patient outcome

13. What do anaesthetists want?
Analgesia
Spinal single/ catheter
Epidural single/ catheter
Lumbar plexus / Psoas single/ catheter
Local infiltration single/ catheter
Femoral; 3 in 1 single/ catheter
Sciatic single/ catheter
Systemic: Opioids / NSAID / Paracetamol
Adjuncts

14. Neuraxial blocks
Low dose intrathecal opiods can provide prolonged analgesia after hip (Murphy et al. 2003) and knee (Bowrey et al. 2003) surgery. (Lesser effect for knee)
Optimal dose for hip surgery 100 micrograms Morphine
Up to 21 hr analgesia (Murphy et al. 2003)
Side effects – PONV/Pruritus/rostral spread with higher doses

15. Neuraxial block better postoperative analgesia
Maurer et al
Elective hip surgery
Continous Spinal Anaesthesia
better postoperative analgesia
Less nausea and vomiting
Compared with single shot spinal followed by patient-controlled intravenous analgesia with morphine

16. Spinal fentanyl vs diamorphine
No direct study
Not mentioned in any systematic review
Obstetric literature extrapolation in C-Section
Fentanyl 20 vs diamorphine 250
2 x analgesia postop up to ~ 18 hours
Cowan 2002, Lane 2005

17. Epidural vs Systemic: Cochrane review 2010
Choi at al revised 2010
‘Epidural analgesia for pain relief following hip or knee replacement’
58 found –only 13 studies used
4 hip/6 knee /3 both
Outcomes
Relevance?
Eg average Hospital Stay 12,16,16,19 days
Small patient numbers: 21-90

18. Epidural vs Systemic: Cochrane review 2010
Choi at al revised 2010
‘Epidural analgesia for pain relief following hip or knee replacement’
Sedation [0.09, 0.97]
Urine Retention [1.63, 7.51]
Hypotension [1.15, 6.72]
Early rest pain [-1.24, -0.31]
Late rest pain [-0.73, 0.16]
Early dynamic pain [-3.43, -1.48]

19. Epidural, continuous femoral nerve block or PCA and effect on rehabilitation after hip arthroplasy
Singelyn et al. 2005
45 patients; hip arthroplasy under GA
3 groups: Epidural / continuous femoral block / PCA
All
similar pain relief,
comparable rehabilitation
duration of hospital stay
Continuous FNB less side effects (nausea/vomiting, urinary retention, hypotension, catheter problems)

20. Epidural analgesia compared with PNB after major knee surgery
Fowler et al. BJA 2008; Systematic review
8 studies included; n=464 knee replacement
Most common PNB :femoral sheath catheter (5), single shot femoral (2), continuous lumbar plexus block (1)
Only 1 epidural vs femoral single shot study; n=63  Adams 2002
Femoral nerve block
Comparable analgesia to epidural but less hypotension
No benefit to adding sciatic nerve block at 24 hrs

21. Peripheral nerve blocks
Advances in ultrasound imaging and nerve localisation plus continuous catheter technology
Increased interest in lower limb peripheral nerve blockade.
Femoral vs PCA
Ng better analgesia
Hunt better analgesia
Wang 2002 better analgesia
Allen 1998 better analgesia

22. Femoral nerve block improves analgesia outcomes after TKA
Paul et al 2010 Anaesthesiology
Meta-analysis of 23 studies
Comparing FNB with PCA or epidural analgesia
1016 patients
Only 153 Femoral single vs PCA
SSFNB improved analgesia and reduced morphine doses compared to PCA
Continuous FNB no better than SSFNB

23. Femoral nerve block improves analgesia outcomes after TKA
PAIN SCORE AT REST: 24 HOURS
Paul et al 2010 Anaesthesiology

24. Psoas compartment block: Hip/Knee
Psoas compartment: posterior Lumbar plexus
Femoral/Obturator/lateral cutaneous nerve thigh
Technique Mannion 2007
Touray et al. BJA 2008: Syst review 30 studies- 20 RCTs
Mildly superior to iv opiates and ‘3-in-1’ block <8 hours
Single injection reduces pain for 4-8hrs
As good as epidural if catheter used
Catheter can extend analgesia beyond 8hrs
Other analgesia may be required (18% -GA TKA)
Complications: epidural extension

25. Lumbar plexus block
Unlike FNB....side effects related to psoas compartment block
Auroy et al 2002 French Survey of 158,083 blocks
Retrospective study on complications
Similar to UK National Audits

26. Lumbar plexus block 394 Lumbar plexus blocks 10,309 Femoral
1 cardiac arrest 0
2 respiratory failures 0
1 seizure 0
peripheral neuropathy 3
1 death 0
High dermatome level and bilateral mydriasis
Suggesting intrathecal cephalad spread of LA

27. Continuous peripheral nerve blocks
Do they provide superior analgesia?
What about side effects and outcomes?

28. Do Continuous Peripheral Nerve Blocks provide superior pain control to opioids 1?
Richman et al A+A 2006
Meta-analysis 12 studies [360 pts] lower limb
Reduced Pain scores 24/48 hours ~ 50%
Reduced side effects OR
Nausea/vomiting .28
Sedation
Pruritus .3
‘Perineural catheters provided superior analgesia to opioids for all catheter locations and times’

29. Do Continuous Peripheral Nerve Blocks provide superior pain control to opioids 2?
Pain score at rest 24 hrs
Pain score at rest 48 hrs
Paul et al 2010 Anaesthesiology

30. Continuous peripheral nerve blocks & falls
Ilfeld et al. Anesth Analg 2010
Pooled data from 3 previously randomised, placebo-controlled studies of continuous – femoral nerve
Knee and Hip arthroplasy
No patients receiving perineural saline fell (n=86)
7 falls in 6/85 patients receiving ropivacaine (7%; 95%CI=3-15%; p=0.013)
Suggests a causal relationship

31. Continuous femoral versus posterior lumbar plexus nerve blocks after hip arthroplasy
Ilfeld et al Anesth Analg 2011
Hypothesis that in terms of postoperative analgesia
femoral ~= posterior lumbar plexus block
n= 47
2 days catheter infusion;
No difference in pain scores
Less walking with femoral block day 1

32. Local infiltration techniques
Alternative method for postoperative pain relief after Hip/Knee arthroplasty
Multimodal wound infiltration analgesic technique consisting of peri-and intraarticular infiltration of local anesthetics, NSAID, Vasoconstrictor (LIA)
Catheter may be placed intraoperatively
(Kerr and Kohan 2008)

33. Local infiltration techniques
Several potential advantages
Analgesia affects only the surgical area with limited interference of the muscle strength
Easier rehabilitation of the operated extremity and earlier discharge from the hospital (Reilly et al. 2005, Essving et al 2009)
Reduces the requirement for postoperative analgesia with opioids
(Tanaka et al. 2001, Busch et al. 2006, Vendittoli et al. 2006)

34. Local infiltration analgesia
Repopularised by Kerr & Kohan (2008)
Case study of 325 patients
Hip and Knee arthroplasty
Described technique

35. Local infiltration analgesia
Repopularised by Kerr & Kohan (2008)
150–170 mL TKR; 150–200 mL THR
2.0 mg/mL Ropivicaine = total dose mg
(~=1.0mg/ml Bupivicaine, max 75kg 2.5mh/kg)
30 mg ketorolac
10 μg/mL adrenaline
50-mL syringes 10-cm-long 19-G spinal needles
Over 1 hour during operation

36. Local infiltration analgesia
Just before wound closure catheter placed
16-G Tuohy needle
18-G epidural catheter
0.22-μm antibacterial epidural filter
50ml reinjected at hours
+ NSAID + codeine + paracetamol
Kerr & Kohan (2008)

37. Local infiltration analgesia: Hip resurfacing
Pain scores /10
N=185

38. Local infiltration analgesia: knee
Pain scores /10
N=86

39. Local infiltration analgesia
Morphine use
Hip Knee
None 69% 57%
None after 24 hours
Stay
Hip resurface THR TKR
Mean 1.3 [1–16] [1–27] 3.2 [1–42]
days stay

40. Local infiltration techniques
Essving 2009
Single centre blinded RCT, n=40
Knee unicompartmental arthroplasty
200 mg ropivacaine, 30 mg ketorolac, and 0.5 mg epinephrine: total volume 106 mL hours top up
vs nothing + placebo top up
All had PCA, paracetamol, tramadol

41. Local infiltration analgesia

42. Local infiltration analgesia

43. Local infiltration techniques
Essving 2009
Median hospital stay
infiltration group Placebo
1 (1–6) days vs 3 (1–6) days (p < 0.001)
Similar Oxford knee scores / satisfaction at 7 days / ability to flew knee at discharge

44. Local infiltration techniques
Few investigators have compared LIA with other methods with proven analgesic effect, eg femoral block or epidural analgesia

45. Local infiltration techniques
Toftdahl et al (2007) n=80 RCT TKA Spinal
LIA with ropivacaine, ketorolac, and epinephrine
vs Femoral block
Less pain score, less opioids day 1
better ability to walk more than 3 m on the first postoperative day
No stay difference
No side effect difference

46. Local infiltration techniques
Affas et al 2011
Compared LIA with femoral nerve block
40 patients undergoing TKA under spinal anesthesia
randomized to
femoral nerve block or
Infiltration with ropivacaine, ketorolac & epinephrine
All patients had to intravenous Morphine (PCA)

47. Local infiltration techniques
The average pain at rest
lower with LIA (1.6) than with femoral block (2.2)
Total morphine consumption per kg was similar
Severe pain(> 7 upon movement)
5% patients in the LIA vs 37% in the femoral block
(p = 0.04)

48. Local infiltration techniques
? LIA provide better analgesia vs femoral block after TKA
LIA may be considered to be superior to femoral block since it is cheaper and easier to perform!

49. Adjuncts
Ketamine
Gabapentanoids

50. Ketamine
Noncompetitive antagonist at NMDA receptors and others (Kors et al. 1998)
Some suggestion a single intra-operative dose (0.15mg/kg) improves passive knee mobilisation after arthroscopic anterior ligament repair surgery (Menigaux et al. 2000)
Improves functional outcome after day case knee arthroplasy (Menigaux et al. 2001)

51. Ketamine: Adam et al. 2008
Low dose IV ketamine in combination with continuous femoral nerve block on postoperative pain and rehabilitation after total knee arthroplasty.

52. Ketamine: Adam et al. 2008 Continuous femoral nerve block
0.3 mL/kg of 0.75% ropivacaine before surgery
continued in the surgical ward for 48 h with 0.2% ropivacaine at 0.1mL/kg/h
Patients randomised to
initial bolus of 0.5 mg/kg ketamine
+ continuous infusion of 3 μg/kg/min during surgery
+ 1.5 μg/kg/min for 48 h ketamine group
vs equal volume of saline control group

53. Ketamine: Adam et al. 2008 Ketamine group
needed less morphine (45 mg versus 69 mg; P 0.02).
reached 90° of active knee flexion more rapidly than those in the control group
7 [5–11] versus 12 [8 – 45] days, median [IQR]; P 0.03).
Outcomes at 6 wk and 3 months were similar

54. Adam et al. 2008
Ketamine is a useful analgesic adjuvant in perioperative multimodal analgesia
Positive impact on early knee mobilization.
No patient in either group reported sedation, hallucinations, nightmares, or diplopia
No differences in PONV between the two groups

55. Gabapentanoids
Reduction of physiological sensitisation induced by nociception and inflammation
? Reduces nerve hyperexcitability
Pregabalin structurally related to gabapentin but 6x more binding affinity (Dahl et al. 2010)

56. Pregabalin Buvanendran 2010 Double blind RCT; n=240
300mg pre-surgery and 150mg BD post operatively for 14 days vs placebo
Immediate postoperative period, epidural drug consumption reduced compared to placebo
No difference in pain scores, but less oral opiods in pregabalin group
Sedation and confusion more frequent in pregabalin group (Day 0 and 1)
Less Chronic months (0, 0 vs 8, 5%)

57. Summary Spinal single/ catheter (diamorph)
Analgesia
Spinal single/ catheter (diamorph)
Epidural single/ catheter yes
Lumbar plexus / Psoas single/ catheter ?
Local infiltration single/ catheter yes
Femoral; 3 in 1 single/ catheter Single FNB
Sciatic single/ catheter No
Systemic: Opioids / NSAID / Paracetamol
Adjuncts ?

58. Conclusions
Acute pain relief to optimise general clinical outcome for the patient
Multi-modal approach
Attempt to prevent persistent post-operative pain
Managing expectations
Context-sensitive environment

59. Questions Problems Small studies- poor power, design eg unblinded,
Statistics rubbish eg
‘average pain score 2.2’ (1-5)
LIA gives control to surgeons +/- interest
Previously ‘our’ area
Many anaesthetists rarely see postop consequences
Recent trend to ‘enhanced’ recovery – different techniques ? Speed ‘important’ vs ‘experience’
Studies looking at only 1 thing eg pain

60. Knee sensory nerves Lumbar spine (L2 3 4) Sacral plexus (L4 5 S1 2 3)
Femoral
Saphenous nerve
Obturator
Sacral plexus (L4 5 S1 2 3)
Posterior cutaneous nerve of the thigh
Sciatic
Popliteal
Tibial
Common Peroneal – superficial/deep

61. Hip Sensory nerves Thoracic Spine (T12 -) Cutaneous
Lumbar spine/plexux (L2 3 4)
Femoral- hip joint and femur
Obturator - hip joint
Lateral cutaneous nerve of the thigh (L2 3)
Sacral plexus (L4 5 S1 2 3)
Sciatic- hip joint

63. references Murphey A & A December 2003 vol. 97 no. 6 1709-1715
Adams European Journal of Anaesthesiology (2002), 19:
Affas Acta Orthopaedica 2011; 82 (3):
Kerr & Kohan (2008) Acta Orthopaedica 2008; 79 (2): 174–183

64. References
Lane et al Fentanyl and diamorphine for Caesarean section Anaesthesia, 2005, 60,p453–457
Cowan Br J Anaesth Sep;89(3):452-8
Paul Anesthesiology 2010; 113:1144–62
Touray BJA vol 101, 6 p750
Richman Anesth Analg 2006;102:248 –57
Ilfield et al Anesth Analg 2011
Mannion. Psoas compartment block. CEACCP Vol 7 Issue 5 p 162 available at

65. references Essving. Acta Orthopaedica 2009; 80 (2): 213–219 213
Adam 2005 Anesth Analg 2005 February; 100(2): 475–480
Buvanendran A. Anesth Analg Jan 1;110(1): Epub 2009 Nov 12

66. Glucocorticoids (Kardash et al. 2008)
Preoperative glucocorticoids reduce postoperative nausea but may also improve analgesia and decrease opioid consumption
Fifty consecutive patients undergoing elective 10 total hip arthroplasty under spinal anesthesia with propofol sedation
randomized, double-blind, placebo-controlled:
either 40 mg dexamethasone
or saline placebo IV before the start of surgery

67. Kardash et al. 2008
IV PCA morphine, ibuprofen 400 mg po q6 h and acetaminophen 650 mg po q6 h were given for 48 h.
Pain (0–10 numeric rating scale, NRS) at rest, side effects, and total cumulative patient-controlled analgesia morphine consumption were recorded q4 h for 48 h.
Dynamic pain NRS score was recorded at 24 h.
C-reactive protein levels were measured in a subgroup of 25 patients at 48 h.

68. High dose steroids
The intraoperative sedation requirement with propofol was significantly increased in the dexamethasone group ( vs mg, P 0.02).
Dynamic pain was greatly reduced in the dexamethasone group (NRS score:2.7, 95% CI: 2.2–3.1 vs 6.8, 6.4 –7.2; P ).
There was no significant effect on pain at rest or cumulative morphine consumption at any time.
C-reactive protein levels at 48 h were markedly reduced by dexamethasone (52.4 mg/mL, 28.2–76.6 vs 194.2, –219.4; P ).