Postoperative

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PROSPECT Recommendations

  • COX-2-selective inhibitors are recommended for their analgesic and opioid-sparing effect (grade A). They should be given in combination with strong opioids for high-intensity pain (grade A), or with weak opioids for moderate- or low-intensity pain (grade D)
  • COX-2-selective inhibitors may be preferred to conventional NSAIDs in the peri-operative setting, in patients who have an increased risk of bleeding, or who are at risk of gastroduodenal ulcer/erosion (grade B)
  • The use of COX-2-selective inhibitors should depend upon assessment of individual patient risks (cardiovascular morbidity, actual or recent gastroduodenal ulcer history, renal function and hepatic function [grade B] or aspirin-sensitive asthma [grade D])
  • Although there is concern about impairment of bone-healing with COX-2-selective inhibitors, there are no conclusive clinical studies to show that they have detrimental effects 

Clinical Practice

  • [None cited}

Transferable Evidence from Other Procedures

  • COX-2-selective inhibitors significantly reduced postoperative pain and the requirement for supplementary analgesia compared with placebo following knee arthroplasty Hubbard et al 2003 Click here for more information
  • Parecoxib (20 or 40 mg) was as effective as ketorolac (30 mg) administered intravenously for postoperative pain scores (for level, onset and duration of analgesia) following total knee arthroplasty (n=208) Rasmussen et al 2002
  • Randomised endoscopic trials in healthy volunteers have shown that COX-2-selective inhibitors are associated with a lower incidence of upper gastrointestinal ulceration compared with conventional NSAIDs for short-term use Harris et al 2001
  • Studies in healthy volunteers demonstrated that COX-2-selective inhibitors had no effect on platelet aggregation Greenberg et al 2000
  • Clinical studies investigating the response to oral challenge with COX-2-selective inhibitors in patients with aspirin-induced asthma have demonstrated that COX-2-selective inhibitors do not have an effect on respiratory function Bavbek et al 2004
  • A study to assess the safety of the COX-2-selective inhibitors parecoxib and valdecoxib following non-cardiac general surgery (including gastrointestinal, orthopaedic, gynaecological, urological, and thoracic surgeries) showed no difference in the incidence of cardiovascular thromboembolic events, renal dysfunction/failure, gastrointestinal ulcer complications, and surgical wound-healing complications, compared with placebo (n=1062) (in press, Anesthesiology)
  • Two clinical trials showed that in patients who had undergone CABG surgery, COX-2-selective inhibitors (valdecoxib and parecoxib) were associated with a higher rate of serious cardiovascular thromboembolic events (including myocardial infarction) compared with placebo Nussmeier et al 2005
  • Hypersensitivity reactions and serious skin reactions (e.g. toxic epidermal necrolysis, Stevens-Johnson syndrome, and erythema multiforme) can occur with all COX-2-selective inhibitors. Serious skin reactions have been reported in association with valdecoxib at a higher rate than with other COX-2-selective agents EMEA 2004a
  • Conventional NSAIDs and COX-2-selective inhibitors have been associated with an increased risk of transient hepatotoxicity. Cases of acute hepatic failure have also been reported. Elderly females, with autoimmune disease, and taking other potentially hepatotoxic drugs, may be most susceptible O'Connor et al 2003
  • Short-term use of COX-2-selective inhibitors or conventional NSAIDs can increase the risk of transient renal impairment, especially in patients with existing renal dysfunction, and both types of agent have been associated with cases of acute renal failure in high-risk patients Cheng et al 2004
  • COX-2-selective inhibitors and conventional NSAIDs may elevate blood pressure, particularly in hypertensive patients receiving antihypertensive medication Cheng et al 2004
  • Although there is some concern that COX-2-selective inhibitors may impair wound healing, evidence from animal and clinical studies is conflicting Blomme et al 2003
  • Conventional NSAIDs and COX-2-selective inhibitors have been associated with impaired bone healing in various animal models and in vitro studies Gajraj 2005a

Total Hip Arthroplasty-Specific Evidence

  • Oral valdecoxib was effective in reducing postoperative pain scores at two doses (20 mg or 40 mg) compared with placebo when administered pre-operatively and then postoperatively (p<0.05 for 6, 12 and 18 h) Camu et al 2002
  • Oral valdecoxib was effective in reducing the requirement for supplementary analgesia compared with placebo (p<0.001) Camu et al 2002
  • Oral valdecoxib is not associated with a significant increase in the incidence of nausea or vomiting compared with placebo Camu et al 2002
  • Study details Camu et al 2002 Click here for more information

PROSPECT Recommendations

  • Conventional NSAIDs are recommended for their analgesic and opioid-sparing effect (grade A). They should be given in combination with strong opioids for high-intensity pain (grade A), or with weak opioids for moderate- or low-intensity pain (grade D)
  • Conventional NSAIDs are not recommended in patients who have an increased risk of bleeding, or who are at risk of gastroduodenal ulcer/erosion (grade B)
  • The use of conventional NSAIDs should depend upon assessment of individual patient risks (bleeding complications including epidural haematoma, cardiovascular morbidity, actual or recent gastroduodenal ulcer history, aspirin-sensitive asthma, renal function and hepatic function) (grade B)
  • Although there is concern about impairment of bone-healing with conventional NSAIDs, there are no conclusive clinical studies to show that they have detrimental effects

Clinical Practice

  • [None cited]

Transferable Evidence from Other Procedures

  • Ketorolac (10 mg orally or 30 mg intravenously) was significantly more effective than placebo for reducing pain scores as shown in a number of studies of orthopaedic surgery (including knee, hip and spinal procedures) Kinsella et al 1992
  • Ketoprofen 100 mg orally significantly reduced VAS scores compared with placebo following spinal fusion (p<0.001; n=50) Aubrun et al 2000
  • Oral keterolac 10 mg was as effective as intramuscular morphine 5 mg or 10 mg for reducing postoperative pain scores after orthopaedic procedures DeAndrade et al 1994
  • Intravenous ketorolac 30 mg was more effective than intravenous morphine 4 mg for reducing postoperative pain scores in one study of total knee replacement surgery (n=196) Rasmussen et al 2002
  • Ketoprofen significantly reduced supplementary analgesia requirements compared with placebo following spinal fusion (p=0.002; n=50) Aubrun et al 2000
  • Ketorolac (30 mg bolus, then 5 mg/h infusion for 24 h) reduced the duration of myocardial ischaemic episodes — compared with placebo — for 24 h following the operation in patients undergoing total hip or knee arthroplasty Beattie et al 1997
  • One randomised trial in patients undergoing transurethral prostatectomy showed that diclofenac did not affect total blood loss compared with placebo Bricker et al 1987
  • Randomised endoscopic trials in healthy volunteers have shown that COX-2-selective inhibitors are associated with a lower incidence of upper gastrointestinal ulceration compared with conventional NSAIDs for short-term use Harris et al 2001
  • Randomised trials in healthy volunteers showed that conventional NSAIDs (ketorolac, naproxen or diclofenac) reduced the platelet aggregation response compared with placebo; ketorolac and naproxen also prolonged bleeding time compared with placebo Greer et al 1999
  • Meta-analyses of randomised, controlled trials showed that peri-operative conventional NSAIDs increased the risk of postoperative bleeding requiring treatment and/or the risk of re-operation for haemostasis after tonsillectomy compared with controls Marret et al 2003
  • A randomised trial in healthy volunteers showed that three conventional NSAIDs (diclofenac, ketorolac and ketoprofen) caused a reversible platelet dysfunction Niemi et al 1997
  • A randomised controlled trial showed that three conventional NSAIDs (diclofenac, ketorolac and ketoprofen) were associated with a similar incidence of surgical site bleeding after elective surgery Forrest et al 2002
  • Aspirin and conventional NSAIDs can induce asthma attacks in patients with aspirin-exacerbated respiratory disease Stevenson 2004
  • Conventional NSAIDs and COX-2-selective inhibitors have been associated with an increased risk of transient hepatotoxicity. Cases of acute hepatic failure have also been reported. Elderly females, with autoimmune disease, and taking other potentially hepatotoxic drugs, may be most susceptible O'Connor et al 2003
  • Short-term use of conventional NSAIDs or COX-2-selective inhibitors can increase the risk of transient renal impairment, especially in patients with existing renal dysfunction, and both types of agent have been associated with cases of acute renal failure in high-risk patients Cheng et al 2004
  • Conventional NSAIDs and COX-2-selective inhibitors may elevate blood pressure, particularly in hypertensive patients receiving antihypertensive medication Cheng et al 2004
  • Conventional NSAIDs and COX-2-selective inhibitors have been associated with impaired bone healing in various animal models and in vitro studies Gajraj 2005a

Total Hip Arthroplasty-Specific Evidence

PROSPECT Recommendations

  • Ketamine cannot be recommended at this time due to a lack of procedure-specific evidence, although analgesic data from other procedures are promising

Clinical Practice

  • Ketamine is associated with a risk of adverse effects on the central nervous system

Transferable Evidence from Other Procedures

  • Studies of ketamine in abdominal, orthopaedic, gastric, hepatic and renal surgery showed a reduction in postoperative pain and opioid use when used as an adjuvant to morphine, either epidurally or intravenously Subramaniam et al 2004

Total Hip Arthroplasty-Specific Evidence

  • [None cited]

PROSPECT Recommendations

  • Strong opioids are recommended in combination with non-opioid analgesia for managing high-intensity pain following total hip arthroplasty (grade B)
  • Intravenous patient-controlled analgesia (grade A) or fixed-interval intravenous administration titrated for pain intensity (grade D), is recommended over 'on-demand' administration
  • Intramuscular administration of strong opioids is not recommended because of injection-associated pain (grade D)

Clinical Practice

  • Strong opioids in equipotent doses are considered to give a similar level of analgesia
  • Intramuscular administration of strong opioids is considered to be more painful than intravenous administration. However, the size and speed of intravenous dose should be assessed to minimise the risk of respiratory depression

Transferable Evidence from Other Procedures

  • Meperidine significantly reduced postoperative pain scores compared with placebo following hip or knee arthroplasty Tarradell et al 1996 Click here for more information
  • Morphine 4 mg was superior for reducing pain scores and reducing the time to onset of analgesia compared with placebo following total knee arthroplasty Rasmussen et al 2002
  • Oral flupirtine maleate 100–200 mg and pentazocine 50–100 mg had similar effects on pain scores and on the requirement for supplementary analgesia after total hip or knee arthroplasty (n=66) Galasko et al 1985
  • Morphine administered by PCA device had a similar effect to continuous infusion on postoperative pain scores following total hip or knee arthroplasty (n=32) Smythe et al 1996
  • Opioids administered by PCA improved analgesia and decreased the risk of pulmonary complications, and patients preferred them compared with conventional intramuscular, intravenous or subcutaneous opioid treatment, as determined in a quantitative systematic review of randomised trials of postoperative pain management following various surgical procedures Walder et al 2001
  • Meperidine induced significantly higher sedation and respiratory depression compared with tramadol (both 100 mg intravenously) (n=48) Tarradell et al 1996

Total Hip Arthroplasty-Specific Evidence

  • Morphine (0.15 mg/kg intramuscularly) was superior to nalbuphine (0.3 mg/kg intramuscularly) for postoperative pain scores (p<0.02) and for the use of supplementary analgesia (p<0.05; n=80) Fee et al 1989
  • Morphine (2 mg bolus) was superior to meptazinol (20 mg bolus) — each given by PCA — for 8 h postoperative pain scores (p<0.05), and for the incidence of nausea and vomiting (p<0.05; n=49) Frater et al 1989
  • Morphine 2 mg and diamorphine 1 mg — given by PCA — were equally effective for reducing postoperative pain scores (n=40) Robinson et al 1991
  • IV PCA morphine 1 mg 8-min lockout was superior to 4-hourly intramuscular morphine 0.1 mg/kg for postoperative pain scores at rest (p<0.01) and on movement (p<0.05) at 24 and 48 h. There was no significant difference between groups for PONV (n=40) Keita et al 2003
  • Oral morphine (20 mg every 4 h) was superior to IM morphine (5–10 mg on demand) for postoperative pain scores (p<0.05; n=47) McCormack et al 1993
  • Oral sustained-release morphine 20 mg every 12 h, starting at premedication, and IM morphine 10 mg every 6 h postoperatively, were similar for VAS pain scores Bourke et al 2000
  • Study details Fee et al 1989 Click here for more information

PROSPECT Recommendations

  • Weak opioids are not recommended for controlling pain <6 h following total hip arthroplasty (grade A)
  • Weak opioids are recommended for moderate- or low-intensity pain after 6 h if conventional NSAIDs or COX-2-selective inhibitors, are insufficient or are contraindicated (grade D)

Clinical Practice

  • It is considered that weak opioids are ineffective as a single therapy for postoperative pain following total hip arthroplasty

Transferable Evidence from Other Procedures

  • Tramadol (100 mg bolus intravenously) provided no benefit over placebo for postoperative pain scores after total hip or knee arthroplasty (n=48) Tarradell et al 1996

 Total Hip Arthroplasty-Specific Evidence

  • Tramadol (50 or 100 mg orally) provided no benefit over placebo for postoperative pain scores up to 5 h after total hip arthroplasty (n=137) Stubhaug et al 1995
  • Codeine (60 mg orally) provided no benefit over placebo for postoperative pain scores up to 6 h after total hip arthroplasty (n=121) Dahl et al 1995

PROSPECT Recommendations

  • Paracetamol is recommended for all pain intensities because it reduces supplementary analgesic requirements immediately following total hip arthroplasty (grade A)
  • Paracetamol is recommended in combination with conventional NSAIDs or COX-2-selective inhibitors, with or without rescue opioids (grade D)

Clinical Practice

  • [None cited]

Transferable Evidence from Other Procedures

Total Hip Arthroplasty-Specific Evidence

  • Parenteral propacetamol 2 g (intravenous infusion) had a significant benefit over placebo in reducing postoperative morphine consumption (p<0.001; n=97) Peduto et al 1998
  • Oral paracetamol 1 g plus codeine 60 mg was superior to placebo and to tramadol (50 or 100 mg) for reducing postoperative pain scores at 2–6 h £ 0.01, all comparisons) and supplementary analgesic use (p<0.01, all comparisons) (n=137) Stubhaug et al 1995
  • Parenteral propacetamol 2 g (intravenous infusion) had no benefit over placebo for reducing postoperative pain scores after total hip arthroplasty (n=97) Peduto et al 1998

PROSPECT Recommendations

  • Epidural infusion with local anaesthetic plus opioid is recommended for cardiopulmonary risk patients (grade A) because of the reduction in cardiopulmonary morbidity associated with epidural analgesia
  • Despite the analgesic benefits of epidural clonidine, it is not recommended for the control of postoperative pain following total hip arthroplasty because of the risk of hypotension, sedation and bradycardia (grades A and D)

Clinical Practice

  • Epidural analgesia is associated with a risk of bladder complaints and neurological impairment, therefore patients are 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

Transferable Evidence from Other Procedures

  • Epidural analgesia was superior to systemic analgesia for postoperative pain outcomes Singelyn et al 1998 Click here for more information
  • Epidural analgesia was associated with a lower incidence of pulmonary complications, sedation, urinary retention, pruritis and hypotension compared with systemic analgesia Ballantyne et al 1998 Click here for more information
  • Ropivacaine epidural infusion was superior to placebo (no epidural infusion) for reducing postoperative pain scores (all groups received rescue IV morphine) Turner et al 1996 Click here for more information
  • A combination of epidural local anaesthetic plus opioid produced superior analgesic benefits compared with either drug administered alone Lorenzini et al 2002 Click here for more information
  • Epidural morphine (bolus 4 mg, infusion 12.5 mg/h over 13 h) was similar to epidural ketoprofen (200 mg over 30 min, 12.5 mg/h over 13 h) for postoperative pain scores following total hip or knee arthroplasty Hommeril et al 1994
  • The addition of epidural clonidine (bolus of 150 µg) to epidural bupivacaine (bolus of 50 mg) significantly prolonged the duration of analgesia in patients undergoing hip surgery for traumatic fracture (p<0.05; n=40) Klimscha et al 1995
  • 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 analgesics in major orthopaedic surgery Holmstrom et al 1993
  • There was no significant difference between epidural fentanyl (3 µg/ml) plus bupivacaine and bupivacaine alone in the rate of regression of sensory anaesthesia or the development of postoperative pain (n=48) Ferrante et al 1993
  • Epidural infusion of ropivacaine (2 mg/ml) plus sufentanil (1 µg/ml) produced a significantly higher incidence of adverse events (pruritus, nausea and vomiting) than ropivacaine alone following major knee surgery (n=115) Lorenzini et al 2002
  • Neuraxial and parenteral opioids are associated with a greater risk of side-effects compared with continuous plexus and peripheral neural blockades after major orthopaedic surgery Sinatra et al 2002

Total Hip Arthroplasty-Specific Evidence

  • 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 bolus (pethidine hydrochloride 60 mg) was superior to IM bolus (pethidine hydrochloride 1 mg/kg) administered postoperatively for pain scores at 0.5 and 1 h (p<0.05), but non-significant for 2–4 h pain scores and supplementary analgesic consumption (n=14) Gustafsson et al 1986
  • Postoperative epidural infusions of bupivacaine, ropivacaine or levobupivacaine were similar for postoperative pain scores, supplementary analgesia and PONV in two studies Bertini et al 2001 Click here for more information
  • Epidural infusion of bupivacaine (0.125 mg/ml) combined with morphine (0.05 mg/ml) was similar to combination with fentanyl (0.005 mg/ml) for postoperative pain scores after total hip arthroplasty (n=30) Berti et al 1998
  • Different epidural sufentanil doses (0.5 µg/ml, 0.75 µg/ml or 1.0 µg/ml) administered with ropivacaine 0.1% by continuous epidural infusion, were similar for VAS scores, supplementary analgesic consumption, pain-mobility-and-ability-to-walk scores and adverse events within 0–44 h (n=32) Kampe et al 2003
  • Epidural clonidine was superior to epidural local anaesthetic or morphine for a number of postoperative analgesia outcomes Carabine et al 1992a Click here for more information
  • Addition of clonidine to local anaesthetic or opioid was superior to local anaesthetic or opioid alone for a variety of postoperative analgesia outcomes Carabine et al 1992a Click here for more information
  • The addition of ropivacaine (1 mg/ml, 3 ml/h) to an infusion of fentanyl (10 µg/ml, 3 ml/h) conferred no benefit over fentanyl alone for postoperative pain scores (n=39) Kostamovaara et al 2001
  • Epidural clonidine reduced mean arterial pressure and heart rate compared with epidural morphine but did not increase the incidence of sedation and did not consistently reduce arterial pressure compared with epidural local anaesthetic Carabine et al 1992b Click here for more information

PROSPECT Recommendations

  • Femoral nerve blocks are recommended (grade B) based on their analgesic efficacy in hip fracture surgery and knee arthroplasty. They are recommended over neuraxial techniques and parenteral opioids based on a reduced risk of side-effects in major orthopaedic surgery (grade B). Supplementary obturator and lateral cutaneous nerve of thigh blocks may be required for analgesia in hip arthroplasty
  • Posterior lumbar plexus blocks (psoas sheath blocks) have a greater efficacy than distal lumbar plexus blocks (femoral nerve blocks) in total hip replacement, and are recommended (grade A). However, they have a potential for more serious complications than the femoral block and the risk/benefit balance should be determined for individual patients.
  • Continuous infusion, patient-controlled or 'on-demand' femoral nerve blocks are recommended over a 'single shot' approach as they provide an extended height of block and a greater duration of analgesia (grade D)  

Clinical Practice

  • 'On-demand', patient-controlled or continuous administration are preferred over a 'single-shot' peripheral neural block for longer-acting pain relief

Transferable Evidence from Other Procedures

  • 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 analgesic requirement compared with control (n=269) Parker et al 2001a
  • '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
  • '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
  • The posterior approach to the lumbar plexus 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
  • Continuous plexus and peripheral neural blocks are associated with a reduced risk of side-effects compared with neuraxial and parenteral opioids, in pain management after major orthopaedic surgery 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
  • 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% or 0.2%) following total knee arthroplasty (n=41) Weber et al 2001
  • Continuous 3-in-1 femoral block 10 ml/h (0.125% bupivacaine plus sufentanil 0.1 µg/ml and clonidine 1 µg/ml) provided no benefit over IV PCA morphine for the incidence of nausea and vomiting although a reduction in catheter problems was noted Singelyn et al 1998
  • As with all regional anaesthetic techniques, peripheral neural blockade has a failure rate and can cause neural injury and local anaesthetic toxicity Cox et al 2003

Total Hip Arthroplasty-Specific Evidence

  • 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
  • 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
  • Femoral nerve block delivered by PCA provided no benefit over delivery by continuous infusion for postoperative pain scores (n=45) Singelyn et al 2001

PROSPECT Recommendations

  • Where appropriate, single bolus spinal morphine (0.1–0.2 mg) plus local anaesthetic is recommended, administered before surgery, as it provides pain relief for up to 24 h (grade A). The decision to use a spinal technique should be based on the overall benefits of spinal anaesthesia/analgesia to each individual patient
  • Spinal clonidine is not recommended because it is less effective than spinal morphine for analgesia (grade A)
  • Short-acting opioids are not recommended because of their shorter duration of effect compared with morphine at appropriate doses (grade D)
  • Continuous spinal administration of morphine following total hip arthroplasty is not recommended due to safety concerns (grade D)

Clinical Practice

  • Spinal local anaesthetics combined with morphine are widely used for postoperative analgesia in clinical practice, although their effects on the incidence of postoperative nausea and vomiting, and on the bladder, 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

Transferable Evidence from Other Procedures

  • 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
  • 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
  • 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
  • Neuraxial opioids are associated with a higher risk of side-effects compared with peripheral neural blocks Sinatra et al 2002
  • Spinal anaesthesia (using bupivacaine or lidocaine) is associated with a higher risk of serious complications than femoral nerve block Auroy et al 2002

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
  • Strong opioid plus local anaesthetic was superior to local anaesthetic alone for postoperative pain scores, requirement for supplementary analgesia and time to first analgesia request, when administered by the spinal route Fernandez-Galinski et al 1996 Click here for more information
  • Different spinal strong opioids or local anaesthetics were similar for postoperative pain scores  Fournier et al 2000a Click here for more information
  • Spinal morphine 1 mg was superior to clonidine 75–100 µg in combination with isobaric bupivacaine 2.75 ml 0.5% for pain scores up to and including 10 h after the operation (p<0.01), time to first analgesia request and use of supplementary analgesia (p<0.05; n=90) Fogarty et al 1993
  • Patient-controlled spinal analgesia was superior to spinal bolus doses on demand in one study for pain Rundshagen et al 1997 Click here for more information
  • A combination of bupivacaine and morphine may cause a greater incidence of vomiting compared with bupivacaine alone Grace et al 1995 Click here for more information
  • 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
  • Spinal clonidine provided no significant benefit over placebo in two of three studies Grace et al 1995 Click here for more information

PROSPECT Recommendations

  • Postoperative continuous wound infusion with local anaesthetic cannot be recommended at this time (grade D) due to lack of procedure-specific evidence, although analgesic data from other procedures are promising
  • Wound infiltration at the drain site is not recommended (grade D) because drains are not recommended

Clinical Practice

  • [None cited]

Transferable Evidence from Other Procedures

Total Hip Arthroplasty-Specific Evidence