6Problems 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 techniquesMany studies use nerve cathetersRecent trend to ‘enhanced’ recovery – different techniques ? Speed ‘important’ vs ‘experience’Studies looking at only 1 thing eg painMany anaesthetists rarely see postop consequencesLocal infiltration gives control to surgeons / interestPreviously ‘our’ area
7What do patients want? total hip arthroplasty (THA) or Macario et al 2008Patients consulting an orthopaedic surgeon about undergoing eithertotal hip arthroplasty (THA) ortotal knee arthroplasty (TKA)Rate the importance of different questions about their care.
8What do patients want? Macario et al 2008 Assembled questions patients might have about joint replacement surgery29 considering undergoing THA and19 patients considering TKRCompleted written survey asking them to rate 30 different questions5 point from 1 (least) to 5 (most important)(Likert scale)
9Patients' overall ranking (median scores) of the importance of addressing questions regarding joint replacement surgeryn= 29 19Hip KneeWill the surgery affect my abilities to care for myself? 5 5Am 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 4Will 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 5Will I receive medication to manage the pain? 4 4
10How will I be able to manage severe pain? Tell me about my prosthesis? Additional questions written in by the patientsHow 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 procedureAm 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?
11What do surgeons want? Bio-psycho-social approach Maintain muscle powerMinimise complicationsActive patient involvement - educationClinical pathways (Barbieri et al 2009)Enhanced recovery (Kehlet et al 2008)Avoid DVTGood physiotherapy
12What do anaesthetists want? Good quality analgesia for patientsRegional techniques: Neuraxial block/Nerve blockMaintain skillsProvide good surgical fieldOptimise patient outcome
14Neuraxial blocksLow 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 MorphineUp to 21 hr analgesia (Murphy et al. 2003)Side effects – PONV/Pruritus/rostral spread with higher doses
15Neuraxial block better postoperative analgesia Maurer et alElective hip surgeryContinous Spinal Anaesthesiabetter postoperative analgesiaLess nausea and vomitingCompared with single shot spinal followed by patient-controlled intravenous analgesia with morphine
16Spinal fentanyl vs diamorphine No direct studyNot mentioned in any systematic reviewObstetric literature extrapolation in C-SectionFentanyl 20 vs diamorphine 2502 x analgesia postop up to ~ 18 hoursCowan 2002, Lane 2005
17Epidural 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 used4 hip/6 knee /3 bothOutcomesRelevance?Eg average Hospital Stay 12,16,16,19 daysSmall patient numbers: 21-90
18Epidural 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]
19Epidural, continuous femoral nerve block or PCA and effect on rehabilitation after hip arthroplasy Singelyn et al. 200545 patients; hip arthroplasy under GA3 groups: Epidural / continuous femoral block / PCAAllsimilar pain relief,comparable rehabilitationduration of hospital stayContinuous FNB less side effects (nausea/vomiting, urinary retention, hypotension, catheter problems)
20Epidural analgesia compared with PNB after major knee surgery Fowler et al. BJA 2008; Systematic review8 studies included; n=464 knee replacementMost 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 2002Femoral nerve blockComparable analgesia to epidural but less hypotensionNo benefit to adding sciatic nerve block at 24 hrs
21Peripheral nerve blocks Advances in ultrasound imaging and nerve localisation plus continuous catheter technologyIncreased interest in lower limb peripheral nerve blockade.Femoral vs PCANg better analgesiaHunt better analgesiaWang 2002 better analgesiaAllen 1998 better analgesia
22Femoral nerve block improves analgesia outcomes after TKA Paul et al 2010 AnaesthesiologyMeta-analysis of 23 studiesComparing FNB with PCA or epidural analgesia1016 patientsOnly 153 Femoral single vs PCASSFNB improved analgesia and reduced morphine doses compared to PCAContinuous FNB no better than SSFNB
23Femoral nerve block improves analgesia outcomes after TKA PAIN SCORE AT REST: 24 HOURSPaul et al 2010 Anaesthesiology
24Psoas compartment block: Hip/Knee Psoas compartment: posterior Lumbar plexusFemoral/Obturator/lateral cutaneous nerve thighTechnique Mannion 2007Touray et al. BJA 2008: Syst review 30 studies- 20 RCTsMildly superior to iv opiates and ‘3-in-1’ block <8 hoursSingle injection reduces pain for 4-8hrsAs good as epidural if catheter usedCatheter can extend analgesia beyond 8hrsOther analgesia may be required (18% -GA TKA)Complications: epidural extension
25Lumbar plexus blockUnlike FNB....side effects related to psoas compartment blockAuroy et al 2002 French Survey of 158,083 blocksRetrospective study on complicationsSimilar to UK National Audits
26Lumbar plexus block 394 Lumbar plexus blocks 10,309 Femoral 1 cardiac arrest 02 respiratory failures 01 seizure 0peripheral neuropathy 31 death 0High dermatome level and bilateral mydriasisSuggesting intrathecal cephalad spread of LA
27Continuous peripheral nerve blocks Do they provide superior analgesia?What about side effects and outcomes?
28Do Continuous Peripheral Nerve Blocks provide superior pain control to opioids 1? Richman et al A+A 2006Meta-analysis 12 studies [360 pts] lower limbReduced Pain scores 24/48 hours ~ 50%Reduced side effects ORNausea/vomiting .28SedationPruritus .3‘Perineural catheters provided superior analgesia to opioids for all catheter locations and times’
29Do Continuous Peripheral Nerve Blocks provide superior pain control to opioids 2? Pain score at rest 24 hrsPain score at rest 48 hrsPaul et al 2010 Anaesthesiology
30Continuous peripheral nerve blocks & falls Ilfeld et al. Anesth Analg 2010Pooled data from 3 previously randomised, placebo-controlled studies of continuous – femoral nerveKnee and Hip arthroplasyNo 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
31Continuous femoral versus posterior lumbar plexus nerve blocks after hip arthroplasy Ilfeld et al Anesth Analg 2011Hypothesis that in terms of postoperative analgesiafemoral ~= posterior lumbar plexus blockn= 472 days catheter infusion;No difference in pain scoresLess walking with femoral block day 1
32Local infiltration techniques Alternative method for postoperative pain relief after Hip/Knee arthroplastyMultimodal 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)
33Local infiltration techniques Several potential advantagesAnalgesia affects only the surgical area with limited interference of the muscle strengthEasier 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)
34Local infiltration analgesia Repopularised by Kerr & Kohan (2008)Case study of 325 patientsHip and Knee arthroplastyDescribed technique
35Local infiltration analgesia Repopularised by Kerr & Kohan (2008)150–170 mL TKR; 150–200 mL THR2.0 mg/mL Ropivicaine = total dose mg(~=1.0mg/ml Bupivicaine, max 75kg 2.5mh/kg)30 mg ketorolac10 μg/mL adrenaline50-mL syringes 10-cm-long 19-G spinal needlesOver 1 hour during operation
36Local infiltration analgesia Just before wound closure catheter placed16-G Tuohy needle18-G epidural catheter0.22-μm antibacterial epidural filter50ml reinjected at hours+ NSAID + codeine + paracetamolKerr & Kohan (2008)
37Local infiltration analgesia: Hip resurfacing Pain scores /10N=185
43Local infiltration techniques Essving 2009Median hospital stayinfiltration group Placebo1 (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
44Local infiltration techniques Few investigators have compared LIA with other methods with proven analgesic effect, eg femoral block or epidural analgesia
45Local infiltration techniques Toftdahl et al (2007) n=80 RCT TKA SpinalLIA with ropivacaine, ketorolac, and epinephrinevs Femoral blockLess pain score, less opioids day 1better ability to walk more than 3 m on the first postoperative dayNo stay differenceNo side effect difference
46Local infiltration techniques Affas et al 2011Compared LIA with femoral nerve block40 patients undergoing TKA under spinal anesthesiarandomized tofemoral nerve block orInfiltration with ropivacaine, ketorolac & epinephrineAll patients had to intravenous Morphine (PCA)
47Local infiltration techniques The average pain at restlower with LIA (1.6) than with femoral block (2.2)Total morphine consumption per kg was similarSevere pain(> 7 upon movement)5% patients in the LIA vs 37% in the femoral block(p = 0.04)
48Local infiltration techniques ? LIA provide better analgesia vs femoral block after TKALIA may be considered to be superior to femoral block since it is cheaper and easier to perform!
50KetamineNoncompetitive 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)
51Ketamine: Adam et al. 2008Low dose IV ketamine in combination with continuous femoral nerve block on postoperative pain and rehabilitation after total knee arthroplasty.
52Ketamine: Adam et al. 2008 Continuous femoral nerve block 0.3 mL/kg of 0.75% ropivacaine before surgerycontinued in the surgical ward for 48 h with 0.2% ropivacaine at 0.1mL/kg/hPatients randomised toinitial 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 groupvs equal volume of saline control group
53Ketamine: 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 group7 [5–11] versus 12 [8 – 45] days, median [IQR]; P 0.03).Outcomes at 6 wk and 3 months were similar
54Adam et al. 2008Ketamine is a useful analgesic adjuvant in perioperative multimodal analgesiaPositive impact on early knee mobilization.No patient in either group reported sedation, hallucinations, nightmares, or diplopiaNo differences in PONV between the two groups
55GabapentanoidsReduction of physiological sensitisation induced by nociception and inflammation? Reduces nerve hyperexcitabilityPregabalin structurally related to gabapentin but 6x more binding affinity (Dahl et al. 2010)
56Pregabalin Buvanendran 2010 Double blind RCT; n=240 300mg pre-surgery and 150mg BD post operatively for 14 days vs placeboImmediate postoperative period, epidural drug consumption reduced compared to placeboNo difference in pain scores, but less oral opiods in pregabalin groupSedation and confusion more frequent in pregabalin group (Day 0 and 1)Less Chronic months (0, 0 vs 8, 5%)
58ConclusionsAcute pain relief to optimise general clinical outcome for the patientMulti-modal approachAttempt to prevent persistent post-operative painManaging expectationsContext-sensitive environment
59Questions Problems Small studies- poor power, design eg unblinded, Statistics rubbish eg‘average pain score 2.2’ (1-5)LIA gives control to surgeons +/- interestPreviously ‘our’ areaMany anaesthetists rarely see postop consequencesRecent trend to ‘enhanced’ recovery – different techniques ? Speed ‘important’ vs ‘experience’Studies looking at only 1 thing eg pain
63references 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
64ReferencesLane et al Fentanyl and diamorphine for Caesarean section Anaesthesia, 2005, 60,p453–457Cowan Br J Anaesth Sep;89(3):452-8Paul Anesthesiology 2010; 113:1144–62Touray BJA vol 101, 6 p750Richman Anesth Analg 2006;102:248 –57Ilfield et al Anesth Analg 2011Mannion. Psoas compartment block. CEACCP Vol 7 Issue 5 p 162 available at
65references Essving. Acta Orthopaedica 2009; 80 (2): 213–219 213 Adam 2005 Anesth Analg 2005 February; 100(2): 475–480Buvanendran A. Anesth Analg Jan 1;110(1): Epub 2009 Nov 12
66Glucocorticoids (Kardash et al. 2008) Preoperative glucocorticoids reduce postoperative nausea but may also improve analgesia and decrease opioid consumptionFifty consecutive patients undergoing elective 10 total hip arthroplasty under spinal anesthesia with propofol sedationrandomized, double-blind, placebo-controlled:either 40 mg dexamethasoneor saline placebo IV before the start of surgery
67Kardash et al. 2008IV 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.
68High dose steroidsThe 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 ).