Broad recommendations

A clinical guideline recommended for use

Index

Objective/s

To enhance the recovery of patients having primary hip and knee replacements by a multimodal programme which facilitates early mobility and discharge.

Rationale/Background

Approximately 600 hip and 600 knee arthroplasties are performed at NNUH each year. Currently our average length of stay is 8 days. Other centres¹ in the UK and abroad have introduced enhanced recovery programmes. These focus on the provision of safe effective analgesia with minimal side-effects which then enable early mobility. Centres adopting the enhanced recovery programme have reduced their length of stay significantly.

The majority of NNUH patients undergoing joint replacement surgery receive continuous epidural analgesia for post-operative pain relief. This can provide good

pain control in many patients, but has unwanted side-effects such as hypotension, urinary retention and impaired mobility. More worryingly, the risk of haematoma and

infection in the epidural space is a rare but catastrophic event which can lead to permanent neurological damage. It is for this reason that we are exploring other forms of pain relief. The technique of high volume peri-articular infiltration is enjoying increasing popularity internationally. Many publications demonstrate its efficacy and lack of serious side-effects.

A multidisciplinary group of clinicians from NNUH visited the Golden National Jubilee Hospital in Glasgow where a technique involving injecting local anaesthetic around the joint, as part of an enhanced recovery programme, has been used successfully in over 3000 patients. After this meeting it was decided to establish a working group and perform the technique on 30 patients initially. Our technique has been modified from theirs in order to accommodate local practices. NNUH orthopaedic wards have both elective and emergency patients on them and therefore it was felt that any local anaesthetic given on the ward should be delivered through a closed system. In this way the risk of infection is minimised.

Enhanced recovery programmes are multimodal and focus on the following elements.

1 Educating GPs and community support services

2 Patient education and support

3 Pre-operative physiotherapy and Occupational Therapy assessment and education

4 Pre-operative anaesthetic and surgical assessment

5 Utilising surgical and anaesthetic techniques which facilitate early mobility

6 Excellent post-operative analgesia allowing early patient mobilisation

7 Intensive post-operative physiotherapy

8 Early discharge with appropriate back-up and follow-up

Early discharge results in improved patient satisfaction and probably lessens infection and thromboembolism

Broad recommendations

The patient is admitted on the day of surgery.

Patients have surgery performed under spinal anaesthesia supplemented by a target controlled infusion of propofol or a light general anaesthetic.

Post-operative pain relief is provided by peri-articular injection of 0.2% Ropivacaine solution followed by an infusion administered through a catheter placed under direct vision at the end of surgery.

The patient is mobilised on the same day of surgery, preferably after four hours. Physiotherapy is continued three times a day thereafter. The patient can be discharged home when they are independently mobile and their pain is controlled by oral analgaesia.

Anaesthetic technique

Pre-medication

Gabapentin 300 mg 2 hours orally pre-op (Omit pre-op dose in those with renal impairment)

Paracetamol 1g orally.

Single shot spinal 2.5-3.0 mLs Bupivicaine plus target controlled infusion propofol for sedation (OR a light GA if anaesthetist prefers)

Ondansetron 4mg iv

Dexamethone 8 mg iv

Diclofenac 75 mg iv if tolerated

Tranxenamic acid 1 gram to minimise blood loss- has 120 minute half-life so give just before tourniquet goes down for TKR and just after incision is made for THR

No opiates

No urinary catheter.

Limit fluids to ~ 1 litre intraoperatively if possible.

Surgeon infiltrates with 150 -200 mls of 0.2% ropivacaine at end of operation.

Surgeon places peri-articular catheter Catheter must be clearly labelled “peri-articular catheter

Infusion set up with McKinley pump.

Ropivacaine 0.2% 200 mLs.

Give 20 mL bolus and set at 8 mLs/ hour-

Local Infiltration technique

Knee arthroplasty.

150–170 mL of ropivacaine is used for Total Knee Replacement. The injection is made in three stages. The first injection is done after the bone surfaces have been

prepared, but before the components have been inserted since access to the posterior capsule is limited once the components are in place. About 30–50 mL is injected through the joint from the front to a depth of 3 mm into the tissues around the posterior joint capsule, using a systematic sequence from one side to the other to ensure uniform delivery to these tissues. The second injection is done after the components have been inserted, but before both wound closure and tourniquet release. About 35–50 mL is injected into the deep tissues around the medial and lateral collateral ligaments and the wound edges. The third injection of 25–50 mL of the same Ropivacaine solution is made into the subcutaneous tissue. Multiple injections are made in a systematic sequence, approximately every 25 mm around the wound. The needle is inserted each time perpendicular to the wound edge to a depth of about 25 mm and injection is done as the needle is withdrawn.

Catheter placement.

Immediately before wound closure, a Touhy needle is inserted about 10 cm above the incision through the skin, subcutaneous tissue, and quadriceps muscles. The tip of the catheter is then inserted through the hub of the needle into the surgical field from the outside to the inside. The catheter is then led along the medial femoral condyle usually on raw bone, medial to the metal femoral component and adjacent to the medial capsule. Using an artery forceps, the tip is then passed posterior to the medial femoral condyle, so that the tip lies immediately anterior to the posterior capsule. Finally, the needle is removed, the slack is taken up and the catheter is cut to a convenient length such that only about 20 cm protrudes from the skin.

The hub and bacterial filter are then connected and about 1–2 mL is injected through the pain catheter to ensure patency. After wound closure, a further 10–15 mL is injected through the catheter to flood the joint with Ropivacaine. The catheter and bacterial filter must be secured firmly to the limb under a sterile transparent adhesive dressing

Hip arthroplasty.

Depending on the size of the surgical incision, 150–200 mL of injectant is injected in stages—in 3 equal 50–70-mL doses. The first injection is made after completion of the acetabular surgery, the second one after insertion of the femoral component, and the final one immediately before the skin is sutured. The first injection is made into the tissues around the rim of the acetabulum, focusing on both the joint capsule if it remains, and around the exposed gluteal and adductor muscles. The injection is done using a systematic sequence around the acetabular rim to ensure uniform delivery to these tissues. The second injection is made into the external rotators, gluteus tendon, and iliotibial band. Multiple injections are done in a systematic sequence every 25 mm or so along the length of the exposure. Care is taken to infiltrate in a fan-wise fashion around the apices of the wound, so that traumatized tissues in these locations are covered. The third injection is made into the subcutaneous tissues under the wound. Multiple injections are performed in a systematic sequence every 25 mm around the wound. The needle is inserted each time perpendicular to the edge of the wound to a depth of about 25 mm and injection is done as the needle is withdrawn.

Catheter placement

Immediately before wound closure, a Touhy needle is inserted about 10 cm below the inferior apex of the incision through the fascial layers and iliotibial band. The tip of the catheter is then inserted through the hub of the needle from the outside into the surgical field, advanced to the superior apex of the wound, and placed with forceps above the piriformis tendon such that its tip lies antero-superior to the joint (within the capsule for a posterior approach. For an anterior approach the catheter is inserted in to the joint anteriorly under the gluteus medius). The slack is taken up so that the catheter lies over the long axis of the wound in the plane over the external rotator muscles. The needle is then removed so that the catheter exits through the skin about 10 cm below the distal end of the incision, and the catheter is cut to a convenient length such that only about 20 cm protrudes from the skin. The hub and bacterial filter are then connected and 1–2 mL is injected through the catheter to ensure patency. After wound closure, a further 10–15 mL is injected through the catheter to flood the joint with Ropivacaine solution. The catheter and bacterial filter are then secured firmly to the limb under a sterile transparent adhesive dressing (Tegaderm or bio-occlusive)

Post-operative infusion

The surgeon infiltrates the wound as described above and places a wound infiltration catheter.

This will be primed and run through a McKinley Infusion Pump or an elastomeric infusion device.

The anaesthetist will prescribe a continuous infusion of ropivacaine 0.2% at 5-8 mLs hourly.

If patient is in pain in recovery a further bolus of 20 mLs can be given through the pump.

Post-operative medications

Regular

Paracetamol 1g PO qds

Gabapentin300 mg bd for 3 - 5 days – 100 mg bd in >70 years)

(Omit in renal impairment)

Oxycontin MR tablets 10 mg bd – review need at 48hours maximum course 3 – 5 days

(5mg bd in >80 years/renal impairment (eGFR < 30mL/min))

Ibuprofen 400 mg tds (If NSAIDS tolerant – i.e. no recent history of NSAID induced asthma, GI problems; renal impairment or heart failure)

Laxatives if necessary – Senna 15mg ON and Lactulose 10mL BD

à Then after 3 days or on discharge stop oxycodone and prescribe

Codeine phosphate 30 - 60mg qds or dihydrocodeine 30mg 4-6 hourly

PRN

Oramorph 5 -10 mg prn 2 hourly for breakthrough pain

(5mg prn 2 hourly > 80 years)

(2.5-5 mg prn 4hourly if eGFR <15mL/min and titrate according to response)

Cyclizine 50mg TDS po/im/iv prn

Ondansetron 4mg bd/tds po/iv prn (maximum of 2 doses)

Ephedrine 30mg PO prn (for dizziness on attempting to mobilise as per protocol.

No history of IHD and Hb > 8.0g/dL)

Please also prescribe sc/im morphine 5mg max 4hourly prn for escape analgesia

On discharge

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