Analgesics
Pain management for knee and hip surgery
Total knee and hip replacement are highly successful and frequently performed procedures for the relief of osteoarthritic pain and stiffness. However, the early days of recovery are often hard work as the joint is initially swollen and sore. Many patients are aware of this and keeping them comfortable is of paramount importance, prompting the Clinically Relevant Question:
How will you manage my pain after the total knee or hip replacement?
A number of different modalities are available to limit post operative pain and exactly which are used and in what amounts varies with each individual and with their particular response. Patients are encouraged to let the staff know how they are feeling so changes can be made or even anticipated to keep their recovery as comfortable as possible.
However, the following describes “the routine” which myself and my Anaesthetist would usually start with and recommend:
Post operative education
Knowing about the procedure and having realistic expectations about recovery is an important element of preparation for the operation - “fore-warned is fore-armed”. I have a comprehensive website for this purpose in addition to the discussions I have with any prospective candidate for surgery.
About joint replacement surgery
The surgery is done as quickly and efficiently as possible so an experienced Surgeon and Operating Team is important. A tourniquet is used to limit bleeding and assist visualisation. The shortest possible tourniquet time helps to limit tissue damage.
Anaesthetic
A Spinal Anaesthetic is highly recommended. This involves injecting a combination of local anaesthetic and opioid into the space around the spinal cord which effectively eliminates feeling from the waist down for the operation, immediate recovery and for up to 24h later.
Usually, a patient can just be sedated after that so they can sleep comfortably during the procedure. It is a huge advantage for the patient to wake up feeling comfortable as it “sets the pattern” for their whole recovery.
At the end of the operation, I inject a local anaesthetic solution directly into the soft tissues around the knee for additional “local” pain relief.
Continued pain relief
If a Spinal anaesthetic is not possible (or not preferred by the patient), PCA (Patient Controlled Analgesia) is used in the first 24-48 h. This involves the patient topping up their own pain medication when they feel uncomfortable by pushing a button which delivers a small amount of additional painkilling medicine into their vein.
Oral analgesics
Oral analgesics are used after that in various combinations and titrated to the individual’s needs, but a typical regime is as follows:
| Doseage | Frequency | Usage | |
|---|---|---|---|
| Panadol | 1000mg | q6h | Baseline medication, continuing |
| Targin/Endone (narcotic) | q6h | Reducing as comfort allows | |
| NSAID (Mobic) | 15mg | Daily | as tolerated for 5 days |
| Lyrica | 75mg | Daily | which potentiates narcotic analgesia |
Extra medication is also available if the patient feels the initial regime is not enough (“for break-through”).
Anti-nausea medicine (Zofran) is given as well to counteract this common side-effect of narcotics.
With this combination, the great majority of patients having a total knee or hip replacement can be kept comfortable, even in those tough early days, when mobilising the Joint is difficult, but critically important.
