EBPOM SATELITE MEETING8TH JULY 2011

DR ROBERT STEPHENSDR SARAH BARNETT

Evidence Based Analgesia for lower limb arthroplasty

Whole talk at www.ucl.ac.uk/anaesthesia/people/stephensOr 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

CD

Problems

Small studies- poor power, less than ideal designMost 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

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 surgery29 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 19Hip 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 4Is there anything I can do to eliminate pain after surgery?4

5Will 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 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?

What do surgeons want?

Bio-psycho-social approachMaintain muscle powerMinimise complicationsActive patient involvement - educationClinical pathways (Barbieri et al 2009)Enhanced recovery (Kehlet et al 2008)Avoid DVTGood physiotherapy

What do anaesthetists want?

Good quality analgesia for patientsRegional techniques: Neuraxial block/Nerve

blockMaintain skillsProvide good surgical fieldOptimise 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. 2003Elective hip surgeryContinous 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 studyNot mentioned in any systematic review

Obstetric literature extrapolation in C-SectionFentanyl 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

OutcomesRelevance?Eg average Hospital Stay 12,16,16,19 daysSmall 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 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]

Epidural, 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 / PCA All

similar pain relief, comparable rehabilitationduration 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 review8 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 analgesiaHunt 2009 better analgesiaWang 2002 better analgesiaAllen 1998 better analgesia

Femoral 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

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 4-8hrsAs good as epidural if catheter used

Catheter can extend analgesia beyond 8hrsOther 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 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 mydriasisSuggesting 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 2006Meta-analysis 12 studies [360 pts] lower limbReduced Pain scores 24/48 hours ~ 50%Reduced side effects OR

Nausea/vomiting .28Sedation .33Pruritus .3

‘Perineural catheters provided superior analgesia to opioids for all catheter locations and times’

Pain score at rest 24 hrs

Pain score at rest 48 hrs

Do Continuous Peripheral Nerve Blocks provide superior pain control to opioids 2?

Paul et al 2010 Anaesthesiology

Continuous peripheral nerve blocks & falls

Ilfeld et al. Anesth Analg 2010Pooled data from 3 previously randomised,

placebo-controlled studies of continuous – femoral nerve

Knee 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

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 blockn= 472 days catheter infusion; No difference in pain scoresLess 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 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)

Local infiltration analgesia

Repopularised by Kerr & Kohan (2008)Case study of 325 patientsHip and Knee arthroplastyDescribed technique

Local infiltration analgesia

Repopularised by Kerr & Kohan (2008)

150–170 mL TKR; 150–200 mL THR2.0 mg/mL Ropivicaine = total dose 250-300 mg

(~=1.0mg/ml Bupivicaine, max 75kg 175mg @ 2.5mh/kg)

30 mg ketorolac 10 μg/mL adrenaline50-mL syringes 10-cm-long 19-G spinal needlesOver 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 /10N=185

Local infiltration analgesia: knee

Pain scores /10N=86

Local infiltration analgesia

Local infiltration techniques

Essving 2009Single centre blinded RCT, n=40Knee 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 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

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 SpinalLIA with ropivacaine, ketorolac, and

epinephrinevs 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 2011Compared LIA with femoral nerve block40 patients undergoing TKA under spinal

anesthesiarandomized 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

similarSevere 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!

Ketamine

Gabapentanoids

Adjuncts

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/hPatients 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 diplopiaNo differences in PONV between the two

groups

Gabapentanoids

Reduction of physiological sensitisation induced by nociception and inflammation

? Reduces nerve hyperexcitabilityPregabalin structurally related to gabapentin

but 6x more binding affinity (Dahl et al. 2010)

Pregabalin

Buvanendran 2010 Double blind RCT; n=240300mg 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 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 approachAttempt to prevent persistent post-operative

painManaging expectationsContext-sensitive environment

Questions

ProblemsSmall 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

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

PoplitealTibialCommon 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):452-8Paul 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 http://ceaccp.oxfordjournals.org/content/7/5/162.full

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).