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Evidence Based Analgesia for lower limb arthroplasty

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

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Evidence Based Analgesia for lower limb arthroplasty

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  1. Evidence Based Analgesia for lower limb arthroplasty EBPOM SATELITE MEETING 8TH JULY 2011 DR ROBERT STEPHENS DR SARAH BARNETT Whole talk at www.ucl.ac.uk/anaesthesia/people/stephens 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 • www.postoppain.org

  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: www.cebm.net 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? • 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? 5 5 How mobile will I be after my surgery? 5 5 When will I be able to walk normally again? 5 5 What are my options if I decide not to receive surgery? 5 4 Will the surgery cause pain afterwards? 5 4 How long will I be in the hospital? 5 4 Is there anything I can do to eliminate pain after surgery?4 5 Will I receive medication to manage the pain? 4 4

  10. 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 • Maurer et al. 2003 • 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 0.30 [0.09, 0.97] • Urine Retention 3.50 [1.63, 7.51] • Hypotension 2.78 [1.15, 6.72] • Early rest pain -0.77 [-1.24, -0.31] • Late rest pain -0.29 [-0.73, 0.16] • Early dynamic pain -2.45 [-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 2001 better analgesia • Hunt 2009 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 .33 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 250-300 mg (~=1.0mg/ml Bupivicaine, max 75kg 175mg @ 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 15-20 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] 4.3 [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 + 21 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)

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