Intra-operative

Expand all

PROSPECT Recommendations

  • The choice of anaesthetic should be based on the co-morbid state of the patient and the contraindications of the proposed anaesthetic technique (grades A and B) rather than on the management of postoperative pain
  • 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)
  • For recommendations on epidural, peripheral nerve block and spinal techniques, see Postoperative section

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
  • It is considered that analgesic drugs should be instituted in time to secure sufficient pain relief when the patient wakes

Transferable Evidence from Other Procedures

  • 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 et al 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 et al 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 Parker et al 2004 Click here for more information
  • 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 et al 2001
  • Peripheral neural blocks are associated with a lower risk of side-effects compared with neuraxial opioids Sinatra et al 2002
  • Femoral nerve block is associated with a lower risk of serious complications than spinal anaesthesia (using bupivacaine or lidocaine) Auroy et al 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 et al 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 JG et al 1998
  • 'Single shot' femoral nerve block reduced pain scores for up to 8 h and reduced morphine consumption following total knee arthroplasty Allen JG et al 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 et al 2002
  • 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 et al 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 et al 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 and Bonnet 1996

Total Hip Arthroplasty-Specific Evidence

  • 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 et al 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 et al 2003
  • Spinal analgesia was superior to epidural analgesia in one study for pain scores Mollmann et al 1999 Click here for more information
  • 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 et al 1999
  • Two studies showed that continuous epidural anaesthesia/analgesia was superior to general anaesthetic plus intravenous morphine analgesia for reducing postoperative pain scores Møiniche et al 1994 Click here for more information
  • 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 et al 2003 Click here for more information
  • Epidural anaesthesia was associated with less intra-operative blood loss than neuroleptoanaesthesia, halothane, phenoperidine or general anaesthesia in four studies Chin et al 1982
  • Epidural catheter insertion with the tip of the Tuohy needle rotated 45° toward the operative side was superior to catheter insertion with the tip of the Tuohy needle in the conventional position (90° 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 et al 2004
  • Posterior lumbar plexus block 'single shot' given pre- or postoperatively was superior to placebo for reducing postoperative pain scores and supplementary analgesic consumption Stevens et al 2000 Click here for more information
  • 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 et al 1998
  • Postoperative lumbar plexus block was superior to femoral nerve block for reducing postoperative pain scores at rest and supplementary analgesic consumption Biboulet et al 2004 Click here for more information
  • 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 et al 2000
  • 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 et al 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 Fournier et al 1998 Click here for more information
  • 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 et al 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 et al 2003
  • There are no studies examining the effects of intra-operative wound infiltration on postoperative pain during total hip arthroplasty
  • Study details Chin et al 1982 Click here for more information

PROSPECT Recommendations

  • It is recommended that surgical requirement rather than pain management should be the main consideration in choosing the surgical procedure (grade D)
  • 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) (grade B)
  • 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)

Clinical Practice

  • Surgical need rather than postoperative pain management should drive the choice of surgical approach

Transferable Evidence from Other Procedures

  • 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 Parker et al 2001b Click here for more information
  • 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 et al 1991
  • 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 et al 2001b
  • There was no significant benefit of drained compared with un-drained wounds for a range of postoperative pain outcomes, including postoperative pain scores Parker et al 2003 Click here for more information

Total Hip Arthroplasty-Specific Evidence

  • 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 et al 1993
  • 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 et al 2001