Key Concepts In Pain Management Following Hip

& Knee Arthroplasty

Dr Pranav BansalAssociate ProfessorDept of Anaesthesiology

& Critical Care

BPS Govt. Medical College for Women, Khanpur Kalan, Sonepat

An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.

IASP Pain Definition (1994, 2008)

According to Katz and Melzack, pain is a personal and subjective experience that can only be felt by the sufferer.

It is easier to find men who will volunteer to die, than to find those who are willing to endure pain with patience. Julius Caesar

What is Pain?

Patients' overall ranking (median scores) of the importance of addressing questions regarding joint replacement surgery: Macario et al 2008

n= 29 19Hip Knee

Will the surgery affect my abilities to care for myself? 5 5Am I going to need physical therapy? 5 5How mobile will I be after my surgery? 5 5When will I be able to walk normally again? 5 5What are my options if I decide not to receive surgery? 5 4Will the surgery cause pain afterwards? 5 4How 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

What do Arthroplasty patients want?

What do surgeons want?

Complete pain free post –operative period but along with:

Early mobilizationEnhanced recoveryMaintained muscle powerMinimal complications

What do Anaesthetists want?

Good quality analgesia for patientsIncorporate newer Regional Anaesthesia

techniques: e.g. Neuraxial blocks with newer additivies and USG guided Nerve blocks to improve outcomes

Maintain clinical skillsOptimise patient outcome

Consequences of poorly managed acute post-operative pain

The Patient may suffer from:

CVS: Tachycardias, Ischaemia

Hypercoagulable state: DVT

Diminished range of joint motion and

Arthrofibrosis are closely related to

the degree of postoperative pain

Psychological: Anxiety, Depression, Sleep Deprivation

Prolonged hospital stays, increased hospital readmissions and increased opioid use

ForThe Healthcare professional:Low MoraleComplaints to/towards/against InstituteLitigation

Consequences of poorly managed acute post-operative pain

Surgical pain

Mild Intensity PainHerniotomyVaricose veinGynecological laparotomy

Moderate Intensity PainHip replacementHysterectomyMaxillofacial

Severe Intensity PainThoracotomyMajor abdominal surgeryKnee surgery

Paracetamol /NSIADs / weak opiodsWound infiltrationRegional block analgesiaAdd weak opioid or rescue analgesia

Paracetamol /NSIADs +Wound infiltrationPeripheral nerve blockSystemic opioidsPCA

Paracetamol /NSIADs+ Wound infiltration Epidural anesthesia Systemic opioidsPCA

Treatment modality

Surgical procedure

Current ProblemsSmall studies- poor power, less than ideal

designToo Many studies, Older studies, Contradictory

outcomesMost studies at single centre i.e. Not the ‘real world’ Rubbish statistics e.g. ‘Average pain score was 2.2 (1-

5)Studies looking at only 1 thing e.g. Pain and fail to

incorporate the concept of ‘Early Mobilisation or Rapid recovery’

How to Evaluate Pain (Scale)

Site of Action of Analgesics

The preparation for Post-Operative Analgesia should start in the Pre-Operative

Period

The administration of analgesic agents prior to an injury in order to prevent development of central nervous system hyperexcitability or sensitization

Preemptive analgesia

Non-Opioid drugs :Antineuropathic : Pregablin 150 mg or Gabapentin 1200 mg

POCOX 2 inhibitors: Celecoxib 400mg or Valdecoxib 40 mg PONSAIDS: Ketorolac 15-30mg PO/IV; Ibuprofen 400-800 mg -Reduce excess intra-operative opioid usage -Reduce the possible effect of opioid-induced hyperalgesia

(paradoxical lowering of pain threshold resulting in greater opioid requirements) post-operatively

This has been referred to as an “Opioid sparing effect.”

Preemptive analgesia

Using rofecoxib 24 hours and 1 hour before surgery with continued postoperative drug administration for 14 days had better outcomes in total knee arthroplasty. These patients showed reduced opioid requirements, faster time to physical rehabilitation, reduced nausea and vomiting, better sleep patterns and greater patient satisfaction after surgery.

Buvanendran A, Kroin JS, Tuman KJ, Lubenow TR, Elmofty D, Moric M, Rosenberg AG. Effects of Perioperative Administration of a Selective Cyclooxygenase 2 Inhibitor on Pain Management and Recovery of Function After Knee Replacement: A Randomized Controlled Trial.JAMA, 2003. 290(18): p. 2411-2418.

Preemptive analgesia

Spinal anesthesia is administered using 10-15mg bupivacaine.

Addition of Fentanyl 20-25 ug increases the post operative analgesia for 2-3 hours.

Addition of Clonidine 25-50 ug increases the post operative analgesia for 6-8 hours.

Addition of Morphine 0.2-0.3 mg extends the post operative analgesia for 12-15 hours.

Intrathecal Analgesics

Epidural Anaesthesia/AnalgesiaEpidural Catheter placed in lumbar segments. LA+ Opioids given via bolus dosing, Infusion

pump or Patient Controlled Analgesia pump•Superior analgesia compared to Intravenous drugs•Reduced systemic opiate requirements•Can extend analgesia for postoperative period

Provides better analgesia than IV drugs at rest and during mobilization.

Can be connected to PCA pump for continuous analgesia.

Side effects:Motor blockade may increase probability of

patient fall during mobilization.In patients on anti-coagulants insertion and

removal of catheter required extra precautionsArterial hypotensionRetention of urine

Epidural Analgesia

Patient Controlled Analgesia Pump

Regime for using Epidural Opioids with LA in PCA pump

Advantages of PCA:Allows patient participation and gives

them autonomy in their treatmentRapid titrationPrecise Analgesic calculations for

scientific studiesReduced analgesic requirementsReduced incidence of breakthrough painLess staffing and monitoring concerns

Drugs for Post-operative analgesiaAcetaminophen (Paracetamol)Excellent drug for Mild to Moderate painTypical dose: 1gm IV every 6-8Hrs (upto 4 g / 24 hrs)

NSAIDs (Diclofenac Sodium, Ketorolac)No physical dependenceCeiling effect Warnings: ↓dose / avoid if: GI ulceration, Renal dysfunction,

Bleeding disorders / Coagulopathy

Tramadol (50-100 mg IV every 6-8 hr)Mild to Moderate Post-op painSide effect: Nausea and Vomiting

Opioids Codiene, Morphine, pethidine, fentanyl,

methadone, sufentanyl, oxycodone

Side Effects include: Nausea / Vomiting, Pruritus, Sedation, Constipation, Urinary Retention, Ileus, Respiratory Depression

Lidocaine (Lox) – fast onset, short duration of actionBupivacaine (Sensorcaine) – slow onset, longer

duration Ropivacaine: longer duration, less cardiotoxic

Local Anaesthetics

Peripheral nerve blocks

Femoral Nerve Block superior to Patient Controlled Analgesia (PCA) in TKA

Femoral block can provide analgesia upto 12-14 hrs following TKA.

Femoral block compared to PCA via Epidural route:

Hunt 2009 better analgesiaWang 2002 better analgesiaNg 2001 better analgesiaAllen 1998 better analgesia

Role of Sciatic Nerve Block in Total knee Replacement

Sciatic nerve provides innervation to posterior part of knee joint

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).

Femoral nerve block Comparable analgesia to epidural but less

hypotensionNo benefit to adding sciatic nerve block at 24 hrs

Psoas compartment block: Hip/Knee Psoas compartment: Femoral/Obturator/lateral

cutaneous nerve thigh

Touray et al. BJA 2008: Syst review 30 studies- 20 RCTsMildly superior to IV opiates and ‘3-in-1’ block <8 hours

Technically DifficultAs good as epidural if catheter used Single injection reduces pain for 4-8hrsOther analgesics required in 18% TKA

Catheter can extend analgesia beyond 8hrsComplications: Epidural extension

Epidural Vs Continuous femoral nerve block Vs PCA and effect on rehabilitation after Hip arthroplasy

Singelyn et al. 200545 patients; Hip arthroplasy under GA3 groups: Epidural / continuous femoral nerve block

(FNB)/ PCA All patients had:

similar pain relief, comparable rehabilitationduration of hospital stay

Patients with Continuous FNB had less side effects (nausea/vomiting, urinary retention, hypotension, catheter problems)

Limitation: Small group size

Local Infiltration TherapyReview Done by Denis Mc Carthy (2013) on

10 RCT’s on Local Infiltration Analgesia following THA showed reduced post operative opioid requirements and more patient satisfaction.

Review by S. Brener (2012) on 13 RCT’s concluded that the impact on pain and length of stay in hospital in patients undergoing either total hip or knee arthroplasty were inconsistent.

Limitation: Different cocktails in varying concentrations and volumes

Ranawat Orthopaedic Center (ROC) cocktail for local infiltration in joint with/without catheter

Medication Strength/dose AmountFirst injection

Bupivacaine 0.5% (200–400 mg)

24 cc

Morphine sulphate 8 mg 0.8 ccEpinephrine

(1:1000)300ug 0.3 cc

Methylprednisolone

40 mg 1 cc

Cefuroxime 750 mg 10 cc (reconstituted in NS)

Sodium chloride 0.9% 22 ccSecond injection

Bupivacaine 0.5% 20 ccSodium chloride 0.9% 20 cc

Clonidine transdermal patch applied in operating room (100ug/24 hours). No steroid in diabetics, immunocompromised, elderly (80 years) or revisions. Vancomycin used if patient allergic to penicillin/ cephalosporins.

Multimodal (Balanced) AnalgesiaUsing more than one drug for pain control

Different drugs with different mechanisms/ sites of action along pain pathway

Each with a lower dose than if used aloneAdditive/ synergistic effects on AnalgesiaLesser side effects (mainly opiate related S/E)

Multimodal analgesia regimes after Arthroplasty at PPMC, Pennsylvania, Philadelphia

Preoperative: Gabapentin 300mg PO + Celecoxib 200mg PO + Acetaminophen 1g PO (2hrs before procedure)

Intraoperative: Spinal anesthesia using 10-15mg bupivacaine

Postoperative: Continuous Femoral nerve or adductor canal block infusion – 0.2% Ropivacaine @ 8-10mls/hr in case of Knee arthroplasty.

Single shot Lumbar plexus or Fascia Iliaca block in case of Hip Joint arthroplasty.

Gabapentin 300mg PO Q8 for 7 Days . Celecoxib 200mg PO for 72 hrs. Acetaminophen 1g PO for 72 hrs.Oxyodone PO IV opioid for breakthrough pain

Spinal single shot (Add Opioids e.g. Morphine)

Epidural catheter YesLumbar plexus/Psoas compartment block ??Local joint infiltration YesFemoral Nere block YesSciatic Nerve Block NoSystemic NSAID’s / Paracetamol YesSystemic: Opioids Yes (titrated)

(In cases of breakthrough pain)

Analgesia after Arthroplasty (In a Nutshell)...

.......In a Nutshell

Prefer Multi-modal approach for an excellent Post Operative analgesia thus leading to:Improved patient satisfaction and Doctor-Patient

relationship.Early MobilisationEarly DischargeReduced Complications↓ likelihood of chronic pain

Thank You