Intra-operative Interventions - ESRA
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Total Hip Arthroplasty 2010

Intra-operative Interventions

Although an intra-operative intervention may be used to produce surgical analgesia, its main effect is measured in the postoperative period. All intra-operative analgesic interventions are considered in the Postoperative section

Total Hip Arthroplasty-Specific Evidence

Studies in this section compared the analgesic benefits and/or safety aspects of different anaesthetic techniques; five studies of anaesthetic techniques assessed safety aspects but did not record pain scores (Chin 1982, D’Ambrosio 1999, Keith 1977, Rosberg 1982, Stevens 2000). For more detail on the analgesic benefits of spinal, epidural and peripheral nerve block techniques, see the Postoperative sections.

Arguments for…

  • Spinal morphine 0.1 mg was superior to a posterior lumbar plexus block using ropivacaine 0.475% for reducing postoperative pain scores for 6–18 h (p<0.05) and reducing supplementary analgesic consumption for 48 h, but there was no significant difference for the incidence of nausea, vomiting or pruritis (n=53) (Souron 2003)
  • Continuous spinal bupivacaine analgesia (and anaesthesia) was superior to IV PCA morphine analgesia (plus ‘single shot’ spinal anaesthesia) for reducing VAS scores for 3–24 h (p<0.05) and the incidence of PONV (n=68) (Maurer 2003)
  • Spinal analgesia with bupivacaine (1 ml 0.25% bolus and 10 ml 0.25% over 24 h) was superior to epidural analgesia with bupivacaine (10 ml 0.25% bolus and 2 ml/h) for postoperative pain scores (n=102; p<0.05), and for the use of supplementary analgesia (p<0.05) (Mollmann 1999).
  • A range of morphine doses (0.025, 0.05, 0.1 and 0.2 mg), administered with bupivacaine 20 mg for spinal anaesthesia, were similar for VAS pain scores (Slappendel 1999)
  • Two studies showed that continuous epidural anaesthesia/analgesia was superior to general anaesthetic plus intravenous morphine analgesia for reducing postoperative pain scores
    • Continuous epidural infusion of bupivacaine 0.625 mg/ml plus morphine 0.05 mg/ml at 4 ml/h for 48 h and piroxicam 40 mg orally (evening before surgery and 1 h before surgery) then piroxicam 20 mg/day, was superior to general anaesthetic followed by intravenous morphine 5 mg and intramuscular morphine 0.125 mg/kg with paracetamol orally on demand for postoperative pain scores on movement, during (p=0.0002) and after (p=0.02) the epidural phase (n=20) (Möiniche 1994).
    • Infused epidural ropivacaine (2 mg/ml at 4–6 ml/h) was superior to general anaesthetic plus postoperative intravenous bolus and on-demand morphine (10 mg and 1.0–1.5 mg via a patient-controlled administration device) for 10- and 24-h pain scores (p<0.001; n=90) (Wulf 1999)
  • Epidural ropivacaine produced a greater proportion of patients with recovered motor function (Bromage score <1) than epidural levobupivacaine and epidural bupivacaine groups immediately postoperatively (p<0.05). However, there were no differences at 6 h (n=45) (Casati 2003)
    • This study assessed the effects of levobupivacaine (0.5% intra-operative epidural block and 0.125% postoperative analgesia), versus bupivacaine (0.5% intra-operative epidural block and 0.125% postoperative analgesia), versus ropivacaine (0.5% intra-operative epidural block and 0.2% postoperative analgesia). Postoperative analgesia using the study drug was administered using a PCEA infusion at a baseline infusion rate 5 ml/h, an incremental bolus 2 ml and lockout time of 20 min. IV ketoprofen was used for supplementary analgesia (n=45) (Casati 2003)
  • Epidural anaesthesia was associated with less intra-operative blood loss than neurolept-anaesthesia, halothane, phenoperidine or general anaesthesia in four studies (Chin 1982, D’Ambrosio 1999, Keith 1977, Rosberg 1982)
  • Epidural catheter insertion with the tip of the Tuohy needle rotated 45 degrees toward the operative side was superior to catheter insertion with the tip of the Tuohy needle in the conventional position (90 degrees cephalad) for reducing postoperative local anaesthetic consumption for 12–48 h (p=0.001), but there was no significant difference for pain scores (n=48) (Borghi 2004)
  • Posterior lumbar plexus block ‘single shot’ given pre- or postoperatively was superior to placebo for reducing postoperative pain scores and supplementary analgesic consumption
    • In two studies ‘single shot’ posterior lumbar plexus block was superior to placebo as follows: lumbar plexus block using 0.4 ml/kg bupivacaine and epinephrine after induction of general anaesthetic was effective in reducing pain scores (p=0.007) and reducing the need for supplementary analgesia (p<0.0001) compared with placebo up to 6 h (n=60) (Stevens 2000); and lumbar plexus block using 2 mg/kg 0.375% bupivacaine plus 2 µg/kg of clonidine at the end of surgery was superior to control (no nerve block) for reducing pain scores at 0–4 h (p=0.001) and opioid use at 0–12 h after extubation (p=0.002) (n=45) (Biboulet 2004).
  • Femoral nerve block (‘single shot’ 40 ml bupivacaine 0.5% plus epinephrine after induction of general anaesthesia) increased the time to first analgesic request by approximately 4 h compared with placebo (p<0.05) (n=40) (Fournier 1998)
  • Postoperative lumbar plexus block was superior to femoral nerve block for reducing postoperative pain scores at rest and supplementary analgesic consumption (Biboulet 2004)
    • In one study, lumbar plexus block was superior to femoral nerve block (each using 2 mg/kg 0.375% bupivacaine plus 2 µg/kg of clonidine ‘single shot’) for reducing pain scores at 0–4 h (p=0.001) and initial opioid use (p=0.004) (n=45) (Biboulet 2004)
  • Addition of a lumbar plexus block to general anaesthesia was associated with less intra-operative blood loss compared with general anaesthesia alone, in one study (n=30) (Stevens 2000)

Arguments against…

  • Continuous spinal bupivacaine demonstrated a significant reduction in mean arterial pressure during anaesthetic induction compared with ‘single shot’ spinal bupivacaine (21 ± 11 mmHg versus 29 ± 14; p<0.05) (n=68) (Maurer 2003)
  • Femoral nerve block did not significantly reduce postoperative pain scores, and there was inconclusive evidence for the effect on supplementary analgesic consumption, compared with placebo
    • In two studies, femoral nerve block showed no significant benefit over placebo for reducing postoperative pain scores as follows: ‘single shot’ 40 ml bupivacaine 0.5% plus epinephrine after induction of general anaesthesia did not reduce postoperative pain scores for 24 h (n=40) (Fournier 1998); and ‘single shot’ 2 mg/kg 0.375% bupivacaine plus 2 µg/kg of clonidine after surgery did not reduce postoperative pain scores at rest or movement for 48 h (n=45) (Biboulet 2004).
    • However, femoral nerve block was superior to control for reducing initial opioid use in one study (p=0.004) (n=45) (Biboulet 2004), but not in the second study at any time (n=40) (Fournier 1998).
  • Posterior lumbar plexus block provided no significant benefit over femoral nerve block or control (no nerve block) for postoperative pain scores on movement, PONV or articular mobility during rehabilitation (n=45) (Biboulet 2004)
  • Posterior lumbar plexus block using ropivacaine 0.475% was less effective than spinal morphine 0.1 mg for reducing pain scores during 6–18 h (p<0.05) and supplementary analgesic consumption during 48 h, and there was no significant difference in the incidence of nausea, vomiting or pruritis (n=53) (Souron 2003)
  • There are no studies examining the effects of intra-operative wound infiltration on postoperative pain during total hip arthroplasty

Transferable Evidence from Other Procedures

Arguments for…

  • Combined spinal epidural block or spinal block were superior to epidural block (0.5% bupivacaine plus 0.2 or 0.4 mg morphine for spinal, or 0.5% bupivacaine plus 4 mg morphine for epidural) for surgical analgesia and for reducing consumption of perioperative sedatives and other analgesics in major orthopaedic surgery (Holmstrom 1993)
  • Epidural anaesthesia reduces the frequency of deep vein thrombosis and pulmonary embolism, and reduces intra-operative and postoperative blood loss, compared with general anaesthesia, particularly in total hip arthroplasty patients, as shown in a review (Modig 1989)
  • Epidural infusion of bupivacaine and meperidine (1 mg/ml) had a significantly slower regression of sensory anaesthesia and slower development of pain, in contrast to infusions of bupivacaine alone (control) or bupivacaine and fentanyl (3 µg/ml) following total knee arthroplasty (p<0.05; n=48) (Ferrante 1993)
  • A systematic review of different methods of anaesthesia for hip fracture surgery showed that regional anaesthesia was associated with reduced short-term mortality compared with general anaesthesia but there was no significant difference for other outcome measures. This review did not report pain scores but is included to provide safety information:
    • Regional anaesthesia was associated with reduced short-term mortality (borderline statistical significance) compared with general anaesthesia but no conclusions could be made about long-term mortality (Parker 2004)
    • Regional and general anaesthesia produced comparable results for other outcome measures, including hypotension, operative blood loss, myocardial infarction, congestive cardiac failure, cerebrovascular accident, renal failure, acute confusional state, urine retention and postoperative vomiting. A reduced risk of deep venous thrombosis was associated with regional compared with general anaesthesia but a firm conclusion could not be made based on available data (Parker 2004)
  • Bolus spinal morphine (300 µg) was significantly more effective than saline placebo for reducing postoperative pain scores after total knee arthroplasty (p<0.05; n=60) (Tan 2001)
  • Peripheral neural blocks are associated with a lower risk of side-effects compared with neuraxial opioids (Sinatra 2002)
  • Femoral nerve block is associated with a lower risk of serious complications than spinal anaesthesia (using bupivacaine or lidocaine) (Auroy 2002)
  • In a systematic review of seven randomised trials in hip fracture, nerve blocks administered pre- or peri-operatively resulted in a reduction in pain score and supplementary analgesia requirement compared with control (n=269) (Parker 2001a)
  • ‘Single shot’ or continuous peripheral nerve block was significantly more effective than placebo for reducing the requirement for supplementary analgesia following total knee or hip arthroplasty (n=242) (Allen 1998, Bogoch 2002, Edwards 1992, Serpell 1989, Wang 2002)
  • ‘Single shot’ femoral nerve block reduced pain scores for up to 8 h and reduced morphine consumption following total knee arthroplasty (Allen 1998)
  • The posterior approach to the lumbar plexus (psoas sheath block) produces more reliable analgesia to the hip joint than the distal approach (femoral nerve or 3-in-1 blocks). However, the lumbar plexus block has the potential for more serious complications than the femoral nerve block (Auroy 2002)

Arguments against…

  • Addition of epinephrine did not alter the duration of analgesia with a ‘single shot’ 3-in-1 femoral nerve block (20 ml ropivacaine 0.5% [~11–12 h] or 0.2% [~7 h]) following total knee arthroplasty (n=41) (Weber 2001)
  • In a systematic review, spinal morphine in patients undergoing caesarean section was shown to increase the relative risk of postoperative pruritis, nausea and vomiting compared with control; increasing the dose of morphine increased the relative risk of postoperative nausea and vomiting (Dahl 1999)
  • Spinal administration of bolus clonidine or morphine produced a high incidence of bladder distension in patients undergoing hip surgery, but there was a greater incidence with spinal morphine than clonidine (p<0.001) (Gentili 1996)

Clinical Practice

  • Spinal anaesthesia and postoperative analgesia using LA and strong opioid is widely used in clinical practice, although the effects on the incidence of postoperative nausea and vomiting, and on urine retention, should be carefully considered before administration.
  • Long-acting opioids, such as morphine, are preferred to short-acting opioids for a long duration of analgesia postoperatively.
  • Both the lumbar plexus block and the femoral nerve block can be used to inject a single bolus of local anaesthetic for short duration of analgesia; or by infusion or PCA via a nerve catheter for a prolonged effect.
  • Epidural analgesia is associated with a risk of bladder complaints and neurological impairment, therefore patients should be assessed for this method of pain relief on an individual basis.
  • Clonidine is not used routinely in postoperative epidural analgesia, despite its analgesic efficacy, because of the risk of hypotension, sedation and bradycardia.
  • Analgesic drugs should be instituted in time to secure sufficient pain relief when the patient wakes.

PROSPECT Recommendations

  • There is insufficient evidence to recommend one anaesthetic technique over another. The choice of anaesthetic technique should be based on the co-morbid state of the patient rather than on the management of postoperative pain (Grade D). Voting agreement: 8/8
  • Depending on the pharmacokinetic profile of the analgesic drugs, it may be necessary to initiate analgesia intra-operatively to allow sufficient time for the analgesia to reach maximum effect in the early postoperative recovery period (grade D). Voting agreement: 8/8

For recommendations on epidural, peripheral nerve block and spinal techniques, see Postoperative section

Total Hip Arthroplasty-Specific Evidence

Arguments for…

  • There was no difference between two surgical methods – the modified Hardinge approach and transtrochanteric lateral approach – in postoperative pain scores in one study (n=100) (Horowitz 1993)

Arguments against…

  • Wound drains were associated with higher pain scores than no drains (no statistical analysis) in one study of patients undergoing total hip arthroplasty (n=23) (Ravikumar 2001)

Transferable Evidence from Other Procedures

Arguments for…

  • Cemented prostheses have been shown to be superior to non-cemented prostheses for long-term reduction of pain and for increasing mobility in patients with fractured neck of femur
    • In a systematic review, cemented prostheses for surgical treatment of fractured neck of femur (review of four trials, 391 participants) were associated with lower pain scores at 1 year or more following the procedure (relative risk 0.51, 95% confidence intervals (CIs) 0.31, 0.81) and a lower risk of failure to regain mobility (relative risk 0.60, 95% CIs 0.44, 0.82) compared with non-cemented prostheses (Parker 2001b).
  • Wound drains without suction produced less postoperative pain intensity on removal compared with drains with suction in intra-articular procedures (n=126; p<0.05) (Brandner 1991)

Arguments against…

  • No benefit of bipolar hemiarthroplasty over unipolar hemiarthroplasty (review of six trials, n=742) was demonstrated for postoperative pain in a range of arthroplasty procedures (Parker 2001b)
  • There was no significant benefit of drained compared with un-drained wounds for a range of postoperative pain outcomes, including postoperative pain scores
    • A systematic review concluded that there were no differences between patients with drained and un-drained wounds for postoperative pain, range of movement, function, late drainage from the wound, swelling of the limb, deep vein thrombosis, mortality, return to work, power and hospital stay following orthopaedic procedures (Parker 2003)
    • Two prospective studies demonstrated that there was no benefit in intra-operative drains for postoperative wound healing, swelling of the wound and postoperative joint movement compared with no drains following total knee or hip arthroplasty (total of 214 knees and 86 hips) (Beer 1991, Ritter 1994)
    • In another prospective study in patients undergoing cemented total knee arthroplasty (n=100), there was no significant benefit of having a single, deep closed-suction drain compared with no drain for postoperative pain scores or swelling (Esler 2003)
    • Wounds with drains in place for >24 h are associated with a greater incidence of infection compared with un-drained wounds (Magee 1976)

Clinical Practice

  • Surgical need rather than postoperative pain management should drive the choice of surgical approach.
  • Cemented prostheses have not been shown to confer any short-term analgesic benefit over non-cemented prostheses, but they are associated with better long-term pain outcomes (>1 year).

PROSPECT Recommendations

  • It is recommended that surgical requirement rather than pain management should be the main consideration in choosing the surgical procedure (grade D). Voting agreement: 8/8
  • Drains are not recommended because they are associated with increased pain scores, do not confer a clinical benefit, and increase the risk of infection (grade B). Voting agreement: 8/8