Gabapentin and Oxycontin must be stopped

Codeine phosphate 30-60mg QDS initiated if not already

à Dihydrocodeine 30mg 4-6hourly as alternative if necessary

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

Information for nurses and junior doctors looking after patients with Local Anaesthetic Infusions for knee and hip replacements as part of the Enhanced recovery Programme

Your patient has had a catheter inserted into their joint by the surgeon. He/she has had 150-200 mLs of 0.2% Ropivacaine injected around the joint at the time of surgery and we are infusing 5-8 mLs/hour of Ropivacaine 0.2% via the wound infusion catheter for 24 hours postoperatively.

The potential benefits are:

Good pain relief

Most patients receive excellent pain relief from this method. It is thought that the blocking of noxious stimuli from the start (with the combination of spinal anaesthesia followed by the local anaesthetic infiltration and infusion) prevents central nervous system sensitisation. This often results in patients requiring minimal pain relief throughout their post-operative period.

Some patients may require a top-up bolus of local anaesthetic solution last thing at night or in the morning before physiotherapy. (Some may require a top-up bolus in recovery. If this is the case call the patients anaesthetist) The McKinley pump is programmed so that 2 or 3 post-operative boluses can be given by an anaesthetist. If you feel your patient needs a bolus please inform the enhanced recovery sister on bleep 1233, in working hours, or the anaesthetic registrar on 0900 at night.

The local anaesthetic infusion is one part of a multimodal technique which includes a cocktail of drugs. These are:

a) gabapentin – this is thought to prevent the pain associated with cut nerves (neuropathic pain). It is used commonly in chronic pain and is now gaining in popularity in post-operative pain. It can make the patient sleepy so it may need to be stopped if your patient seems sedated.

b) Oxycontin - this is the controlled-release formulation of oxycodone (oxynorm). Oxycodone is a synthetic opioid and is popular in enhanced recovery programs because of its quick and reliable onset. Oxycontin gives peak pain relief in approximately 45 minutes and the effects last for 12 hours. The controlled release formulation Oxycontin is given twice a day. Any breakthrough pain can be treated with standard oxycodone (oxynorm) or oromorph. (We have chosen oromorph preferentially because it only requires one nurse to administer it). If for some reason the patient can't take oral morphine they can have intramuscular morphine. Oxycodone has the same side effects as other opiates and so nausea and vomiting, sedation and respiratory depression may occur.

c) Paracetamol/ibuprofen. Patients will be prescribed both these drugs regularly (unless they are intolerant of NSAIDs or have renal problems) Please give these tablets regularly whether the patient is in pain or not.

Some patients are reluctant to take pain-killers if they are not in pain but explain to them that it is better to STOP the pain breaking through and then having to have morphine and all its side-effects.

It is very important the patient receives their oxycontin/paracetamol/ibuprofen on time as it is much easier to prevent pain than treat it once it has broken through.

d) Temazepam/Zopiclone Some enhanced recovery programmes prescribe these drugs on the first and second post-operative night to help patients sleep It is felt that the more rested a patient is the more refreshed they will be in the morning for their mobilisation. If you feel your patient would benefit ask the doctor to prescribe it.

e) Lactulose Please ensure that the patient has an aperient written up.

Good mobility

Unlike epidurals or femoral nerve blocks these infusions do not impair the patients ability to weight bear.

These patients are mobilised four hours after the operation and three times a day thereafter.

Providing that the patient’s systolic blood pressure is within 10% of its pre-operative reading the patient will be mobilised four hours after surgery (Day 0)

On the first post-operative day and thereafter, if a patient feels dizzy on attempting to mobilise, or their BP drops to below 80 mmHG systolic im ephedrine 15mg can be given and mobilisation is attempted again after 30 minutes (Provided that their Hb is greater than 8 g/dl)

Early mobilisation after joint surgery results in a better long term outcome, reduced risk of thromboembolism and possibly infection. Early mobilisation also leads to reduced length of hospital stay. If all is well these patients can go home on the 4^th post-operative day.

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