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Local Infiltration Analgesia Reduces
Length of Stay and Complications
David Mitchell, Orthopaedic Surgeon Ballarat Base Hospital St John of God Ballarat Ballarat Day Procedure Centre
Thursday 31st October, 2013. Australian & New Zealand Orthopaedic Nurses Association
1993: John Repecci Combined local anaesthetic and partial knee replacement.
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Primary Hip & Knee Replacement 2012
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Local Infiltration Analgesia Relies on systematic infiltration and re-injection of surgical field with:
Local anaesthetic (ropivacaine) Directly acting NSAID (ketorolac) Vasoconstrictor (adrenaline) Other drugs (dexamethasone)
Naropin 175ml 0.2% Torodol 30mg Adrenaline 0.5mg Dexamethasone 4mg L N i if >80
The Intraoperative Mix
Where to inject
Hip Catheter placement
Bandage
LIA Controls Pain where it starts Targets all elements involved in local generation of
pain signals: Pain mediators Nerve endings “biological inflammatory soup”
LIA is our primary pain management Not something we add to morphine to control pain Removes the need for PCA opioids, nerve blocks and
epidurals
Drug Chart Kefzol 1g 8/24 x 2
Cartia EC 100mg (6/52) + stockings + mobilize
Paracetamol 1g o/iv 6/24
Mobic 7.5mg bd
Norspan 5 (Buprenorphine)
Tramal 50mg i-ii 4/24 prn
Movicol I sachet bd
Fluid bolus before mobilizing?
As of June 2013
Pain Scores – Old Style - PCA
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Pain
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Pain Score at Rest Pain Score Activity
Pain scores - LIA
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Pain Score at rest
Recovery Room Ice packs immediately
Both of these questions get answered “YES” “Are you comfortable” “Do you have any pain?”
Narcotics = nausea
Reassurance & wound top ups
Are you comfortable? 0 No pain
1-3 I know I’ve had an operation but I think a few pills will fix it
5 The pain is starting to become distressing. I would like some morphine soon
7 Physical signs are prominent. Sweat on brow, teeth clenched, pale and drawn cannot lie still in bed
10 Worst possible pain. "I can hear you screaming from the car park"
Is LIA safe?
Pharmacology
Preop assessment Investigations & history RAPT score
Discharge criteria
Followup phone call
Ropivacaine
Inherently safer than bupivicaine
2468 cases with zero incidence of: Seizures Cardiotoxicity Respiratory arrest Profound hypotension
Reference Kerr DR and Kohan L..
Is the Ketorolac Safe?
Kerr says no problems so far with Ulceration Renal failure Bleeding Endoprosthetic fixation
Reference Kerr DR and Kohan L. Data on File
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Time (min)
Serum Ketorolac level (Kerr data)
BHR
UNI
Cont
TKR
30 mg IM Ketorolac
BHR
TKR UKR
Modifications >80yrs or <60kg
125ml Naropin 0.2%, 50ml Saline
Poor renal function / hx failure No NSAIDs (<5% of time)
Peptic ulceration Add Losec 20mg daily
Bilaterals 125ml Naropin / side Top up 15mg Toradol / side But I rarely do bilateral now…
Pain Patch Norspan 5
Buprenorphine Partial opiod agonist Front of shoulder Don’t get too hot! 7 days – not quite: change at 6
Fentanyl 25ug/hr 3 day action
Tramal Tramadol 50-100mg 4/24 prn
u-opioid binding, noradrenaline & serotonin reuptake inhibitors
BETTER than Endone when used in combination…
Serotonin syndrome NOT seen so far despite use in combination of moderate and high dose SSRI
5% won’t tolerate: hallucinations or nausea
How does LIA reduce complications? DVT / PE / Death
Haematoma
Deep Infections
Chest / UTI / pressure sore
Confusion
Chronic pain
Don’t tie the patient down!!!
No drain
No urinary catheter
No painbuster or PCAS
No IV by 8 hours
No oxygen
D0 Ward activity Nursing
Ice packs Oxygen only if hypoxic or drowsy Top up wound Naropin & Toradol
Physiotherapy Patient must walk Knee extension exercises CPM usually NOT used No ROM exercises until 24 hours
Diet Gatorade/Postop/Pear juice
D1 Ward activity Nursing
Ice packs Oxygen only if hypoxic or drowsy Fentanyl patches (knees only) Top up wound Naropin & Toradol Any Drains / catheter out, IV bung only
Physiotherapy Patient must walk ROM starts - expect 45-60 degrees CPM usually NOT used
Diet Gatorade, no juices, no prawns
Simplified Physio Program
Walk
Straighten knee
Bend knee (d2 & after)
Kneeling exercises at six weeks
It took a while to get it right… Ice packs rarely used
Fasting -> NSAID not used
Narcotic excess -> Nausea
Diminished early mobilization
Inadequate compression -> Swelling
Everyone singing from same songsheet
Sydney (Kerr & Kohan) 2008-09
Discharges on day after surgery
Hip Resurfacing 97% Knee Replacement 71% Hip Replacement 75%
Earlier results: Kerr & Kohan, Acta Orthopaedica, 2008 92(2) 174-
Hours postop until mobile Walking (range) Independent
Hip Resurfacing 9 (2.7-26) 21 (10-51)
Hip Replacement 11 (3.6-29) 24 (7-50)
Knee Replacement 13 (2.7-39) 20 (8-63)
Kerr & Kohan, Acta Orthopaedica, 2008 92(2) 174-
Richard A. Berger MD, Illinois
Presentation at AAOS Meeting
94% of study group discharged on day of surgery
111 pts, 2006Jan-Oct, 25UKA, BMI 18-43, 48-85yo
Nausea most common problem
3.6% readmission rate
What determines length of stay? Pain management
Nausea / vomiting
Mobility
DVT drugs
Discharge planning
Surgeon confidence
Preop RAPT Score Age <66=2 66-75=1 >75=0
Sex M=2 F=1
Walking >2block=2 <2=1 house=0
Aids none=2 stick=1 frame=0
Supports HH/MOW/DN <2/wk=1 2+/wk=0
Carer after surgery? Y=3 N=0
Score out of 12: <6 rehab >9 absolutely no doubt about home
Discharge criteria Adequate pain control & tablets arranged
Hb 80 or preferably >100 if old
No uncontrolled co-morbidities
Appropriate attitude
Independent
Suitable home & someone to "care for them”
Suitable transport arrangement
Rescue plan - phone numbers etc
Kerr & Kohan, 2008, Acta Orthopaedica
Signature
Signature true picture
CRP after TKR
020406080
100120140
Rod, Tourn,no dex
Rod, noTourn, no
dex
No Rod, noTourn, no
Dex
No Rod, NoTourn, with
Dex
Day 1Day 2Day 12
James Tan, John Dillon, presented Vic AOA February 2013
Complications Nausea, Constipation
Wound bleeding / dressing changes
Hypotension & Syncope
Renal failure
Retained catheter
Bleeding duodenal ulcer
PE day 2
Nausea Management Minimise fasting
Minimise narcotics
Stemetil 5mg o tds for nausea
Ondansetron 4-8mg IV bd for vomiting
No acidic juices - use Gatorade or PostOp
Reduce analgesics if no pain
DVT Prophylaxis Aspirin EC 100mg / day
Venosan Silverline (better than TED)
Early mobilization
Avoid intramedullary jigs / coagulation cascade activation
Potent anticoagulants have wrong risk benefit ratio…
DVT After Joint Replacement
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Perc
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Week
THRTKR
White et al, Arch Intern Med, 1998. 19586 primary THRs 24059 primary TKRs
PE after Joint Replacement
00.10.20.30.4
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Perc
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Week
THRTKR
White et al, Arch Intern Med, 1998. 19586 primary THRs 24059 primary TKRs
Chronic Pain after TKR
Australian and New Zealand College of Anaesthetists (ANZCA) and the Faculty of Pain Medicine. Acute pain management: scientific evidence, 2nd edition, 2005.
PHASE TIMEFRAME SOLUTION
Pre-operative Education, building confidence and rapport
Anaesthesia Anaesthesia – Spinal +/- GA
Acute Post-operative
About 36 hours LIA, nerve blocks / catheters, PCAS
Residual 2 weeks Oral or transdermal medication
Chronic
Pain still present at 3 week
Ketamine, gabapentin, amitriptyline
Problem with ROM, Pain, Activity
Identify & Act EARLY
Is pain properly managed?
Raz, Review
Could it have been predicted?
Full Program Preoperative education & discharge planning
MRI / CT Guidance (Signature)
Intra-operative injection
Compression Bandage
Early mobilisation
Top up & Re-injection
NSAIDs, Norspan, Tramal
Preoperative Check List
Things that make a difference
Preop check list
Singing from same song sheet
Phone call after discharge
Measurement & feedback loop
