Local Infiltration Analgesia Reduces. Length of Stay and Complications

Transcription

1 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 31 st October, Australian & New Zealand Orthopaedic Nurses Association

2 1993: John Repecci Combined local anaesthetic and partial knee replacement.

3

4

5

6 Primary Hip & Knee Replacement Number of patients Day of Discharge

7 Primary Hip & Knee Replacement Number of patients Age

8 8 TKR Average Length of Stay Days

9 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)

10 The Intraoperative Mix Naropin 175ml 0.2% Torodol 30mg Adrenaline 0.5mg Dexamethasone 4mg

11

12 Where to inject

13 Hip Catheter placement

14 Bandage

15 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

16

17 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

18 Pain Scores Old Style - PCA Pain Score Days Post Op Pain Score at Rest Pain Score Activity

19 Pain scores - LIA Pain Score - LIA Pain Score Days Post Op Pain Score at rest

20 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

21 Are you comfortable? No pain I know I ve had an operation but I think a few pills will fix it The pain is starting to become distressing. I would like some morphine soon Physical signs are prominent. Sweat on brow, teeth clenched, pale and drawn cannot lie still in bed Worst possible pain. "I can hear you screaming from the car park"

22 Is LIA safe? Pharmacology Preop assessment Investigations & history RAPT score Discharge criteria Followup phone call

23 Ropivacaine Inherently safer than bupivicaine 2468 cases with zero incidence of: Seizures Cardiotoxicity Respiratory arrest Profound hypotension Reference Kerr DR and Kohan L..

24

25 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

26 Serum Ketorolac level (Kerr data) mg IM Ketorolac.5 BHR UNI Cont TKR UKR BHR TKR Time (min)

27 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

28 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

29 Tramal Tramadol mg 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

30 How does LIA reduce complications? DVT / PE / Death Haematoma Deep Infections Chest / UTI / pressure sore Confusion Chronic pain

31 Don t tie the patient down!!! No drain No urinary catheter No painbuster or PCAS No IV by 8 hours No oxygen

32

33 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

34 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 degrees CPM usually NOT used Diet Gatorade, no juices, no prawns

35 Simplified Physio Program Walk Straighten knee Bend knee (d2 & after) Kneeling exercises at six weeks

36

37 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

38 Sydney (Kerr & Kohan) Discharges on day after surgery Hip Resurfacing 97% Knee Replacement 71% Hip Replacement 75% Earlier results: Kerr & Kohan, Acta Orthopaedica, (2) 174-

39 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, (2) 174-

40 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

41 What determines length of stay? Pain management Nausea / vomiting Mobility DVT drugs Discharge planning Surgeon confidence

42 Preop RAPT Score Age <66= =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

43 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

44 Signature

45 Signature true picture

46 CRP after TKR Rod, Tourn, no dex Rod, no Tourn, no dex No Rod, no Tourn, no Dex No Rod, No Tourn, with Dex Day 1 Day 2 Day 12 James Tan, John Dillon, presented Vic AOA February 2013

47 Complications Nausea, Constipation Wound bleeding / dressing changes Hypotension & Syncope Renal failure Retained catheter Bleeding duodenal ulcer PE day 2

48 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

49 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

50 DVT After Joint Replacement Percentage THR TKR Week White et al, Arch Intern Med, primary THRs primary TKRs

51 PE after Joint Replacement Percentage THR TKR Week White et al, Arch Intern Med, primary THRs primary TKRs

52

53 Chronic Pain after TKR PHASE TIMEFRAME SOLUTION Pre-operative Education, building confidence and rapport Anaesthesia Anaesthesia Spinal +/- GA Acute Postoperative 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 Australian and New Zealand College of Anaesthetists (ANZCA) and the Faculty of Pain Medicine. Acute pain management: scientific evidence, 2 nd edition, 2005.

54 Problem with ROM, Pain, Activity Identify & Act EARLY Is pain properly managed? Raz, Review Could it have been predicted?

55 Full Program Preoperative education & discharge planning MRI / CT Guidance (Signature) Intra-operative injection Compression Bandage Early mobilisation Top up & Re-injection NSAIDs, Norspan, Tramal

56 Preoperative Check List

57 Things that make a difference Preop check list Singing from same song sheet Phone call after discharge Measurement & feedback loop

58 Thank you. David Mitchell