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Evidence Based Analgesia for lower limb arthroplasty EBPOM SATELITE MEETING 8 TH J U L Y 2 0 1 1 DR ROBERT STEPHENS DR SARAH BARNETT Whole talk at www.ucl.ac.uk/anaesthesia/people/stephens Or Google ucl anaesthesia stephens 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 How to think about this.. ‘Evidence based’ What do patients want? What do surgeons want? What do anaesthetists want? Levels of Evidence Oxford Centre for Evidence-based Medicine: www.cebm.net From Owww.cebm.net A B C D 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 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. 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) 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 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? 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 What do anaesthetists want? Good quality analgesia for patients Regional techniques: Neuraxial block/Nerve block Maintain skills Provide good surgical field Optimise patient outcome 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 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 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 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 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 Epidural vs Systemic: Cochrane review 2010 Choi at al revised 2010 ‘Epidural analgesia for pain relief following hip or knee replacement’ Sedation Urine Retention Hypotension Early rest pain Late rest pain Early dynamic pain 0.30 [0.09, 0.97] 3.50 [1.63, 7.51] 2.78 [1.15, 6.72] -0.77 [-1.24, -0.31] -0.29 [-0.73, 0.16] -2.45 [-3.43, -1.48] 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) 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 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 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 Femoral nerve block improves analgesia outcomes after TKA PAIN SCORE AT REST: 24 HOURS Paul et al 2010 Anaesthesiology 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 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 Lumbar plexus block 394 Lumbar plexus blocks 1 cardiac arrest 2 respiratory failures 1 seizure peripheral neuropathy 1 death 10,309 Femoral 0 0 0 3 0 High dermatome level and bilateral mydriasis Suggesting intrathecal cephalad spread of LA Continuous peripheral nerve blocks Do they provide superior analgesia? What about side effects and outcomes? 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 Nausea/vomiting Sedation Pruritus OR .28 .33 .3 ‘Perineural catheters provided superior analgesia to opioids for all catheter locations and times’ 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 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 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 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) 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) Local infiltration analgesia Repopularised by Kerr & Kohan (2008) Case study of 325 patients Hip and Knee arthroplasty Described technique 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 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) Local infiltration analgesia: Hip resurfacing Pain scores /10 N=185 Local infiltration analgesia: knee Pain scores /10 N=86 Local infiltration analgesia Morphine use None Hip 69% Knee 57% None after 24 hours Stay Mean days stay Hip resurface 1.3 [1–16] THR TKR 4.3 [1–27] 3.2 [1–42] 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 Local infiltration analgesia Local infiltration analgesia Local infiltration techniques Essving 2009 Median hospital stay infiltration group 1 (1–6) days vs Placebo 3 (1–6) days (p < 0.001) Similar Oxford knee scores / satisfaction at 7 days / ability to flew knee at discharge Local infiltration techniques Few investigators have compared LIA with other methods with proven analgesic effect, eg femoral block or epidural analgesia 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 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) 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) 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! Adjuncts Ketamine Gabapentanoids 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) 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. 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 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 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 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) 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 pain @ 3 + 6 months (0, 0 vs 8, 5%) Summary 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 ? 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 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 Knee sensory nerves Lumbar spine (L2 3 4) Femoral Saphenous nerve Obturator Sacral plexus (L4 5 S1 2 3) Posterior cutaneous nerve of the thigh Sciatic Popliteal Tibial Common Peroneal – superficial/deep 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 references Murphey A & A December 2003 vol. 97 no. 6 1709- 1715 Adams European Journal of Anaesthesiology (2002), 19: 658-665 Affas Acta Orthopaedica 2011; 82 (3): Kerr & Kohan (2008) Acta Orthopaedica 2008; 79 (2): 174–183 References Lane et al Fentanyl and diamorphine for Caesarean section Anaesthesia, 2005, 60,p453–457 Cowan Br J Anaesth. 2002 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 http://ceaccp.oxfordjournals.org/content/7/5/162.f ull references Essving. Acta Orthopaedica 2009; 80 (2): 213–219 213 Adam 2005 Anesth Analg 2005 February; 100(2): 475–480 Buvanendran A. Anesth Analg. 2010 Jan 1;110(1):199-207. Epub 2009 Nov 12 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 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. High dose steroids The intraoperative sedation requirement with propofol was significantly increased in the dexamethasone group (234.6 160.1 vs 138.8 122.7 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 0.0001). 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, 168.9 –219.4; P 0.0001).
