Local Infiltration Analgesia : a Technique to Improve Outcomes after Hip, Knee or Lumbar Spine Surgery

130 Pages·2012·1.15 MB·English

by  Kerr

Local
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A Technique to
Improve Outcomes
after Hip, Knee or
Lumbar Spine Surgery
Dennis R Kerr
Local Infiltration
Analgesia
Publication supported by Astra Zeneca
AstraZeneca Pty Ltd
5 Alma Rd, North Ryde
NSW 2113
Australia
Local Infiltration
Analgesia
A Technique to Improve Outcomes after Hip,
Knee and Lumbar Spine Surgery
Dennis R. Kerr
MBBS, MHA, FANZCA, FCICM, DipABA, FHKCA, FHKAM
Joint Orthopaedic Centre, Bondi Junction,
New South Wales, Australia
CRC Press
Taylor & Francis Group
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Boca Raton, FL 33487-2742
© 2012 by Taylor & Francis Group, LLC
CRC Press is an imprint of Taylor & Francis Group, an Informa business
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Version Date: 20130307
International Standard Book Number-13: 978-1-4398-1179-5 (eBook - PDF)
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This book is dedicated to the memory of my father, Alexander Thynne Kerr,
and my mother, Thelma Gladys Kerr (nee Olsen), pioneers from the
Quandialla district of central New South Wales. Starting from
nothing they struggled through depression, war, fl ood, and drought to
carve our family farm out of the wilderness. Their tenacity,
determination, and sheer hard work provided me with the opportunity to
gain an education and eventually to fulfi l my dream of a career
in medicine. I am extremely proud of them both.
Contents
Foreword vii
Lawrence Kohan
Preface viii
1. How it all started 1
2. Physiology and anatomy 11
3. Local infi ltration analgesia – technique 20
4. Safety issues 33
5. Outcomes 47
6. Thromboprophylaxis and local infi ltration analgesia 56
7. Local infi ltration analgesia and infection 70
8. Local infi ltration analgesia for lumbar spine surgery 75
Peter J. Papantoniou and Dennis R. Kerr
9. Post-operative care 85
10. Implementation: Making it work 91
Appendix 1 Ropivacaine 96
Appendix 2 Local anaesthetic toxicity 98
Appendix 3 Lipid rescue protocol 100
Appendix 4 Patient information sheets 101
Appendix 5 Staff information 109
Index 115
vi
Foreword
The concept of integrating pain management into the surgical process as a single entity is
new. As surgeons, we are generally not trained in the management of postoperative pain,
other than in its most basic form, or at least we were not up until now. The challenges of
surgery, its decision-making process, patient selection, surgical techniques, and imple-
mentation of treatment options, were generally thought to be the limits of our domain.
Pain management was passed on to someone else.
A visit to Dr John Repicci in 1998 was a seminal event. The use of local anaesthet-
ics to block postoperative pain at the site of its generation enabling early mobilization
after joint replacement surgery was a revelation. Dennis Kerr has taken the concept and
refi ned it into a management program allowing early mobilization and dramatic pain
control in the early postoperative period. This multimodal technique is now developed to
the point where it can be applied beyond lower limb arthroplasty surgery, to spinal surgery,
and fi elds outside orthopaedics.
This work is about instituting an “enabling” process. This process begins with sur-
gery but does not stop there. Surgery is the initiating factor, but not the end! Dennis Kerr’s
work in researching medications, applicable doses, administration, interactions, follow-
up, and result analysis has revolutionized the postoperative management of my patients
with elective joint replacement surgery. They have benefi ted through an early recovery
process, a dramatic decrease in complications, and an early return to daily living activities.
However, the initial efforts at presenting and publishing his work were not at all
enthusiastically received. I am reminded of one journal reviewer who, in his rejection let-
ter, described it as a “quirky and idiosyncratic technique.” Nevertheless, he persisted. The
obviously superior patient outcomes were at all times an encouraging and motivating
factor. The technique has now been widely adopted, and continues to be adopted with
increasing frequency, as the advantages become increasingly apparent.
He should be congratulated in producing this work. This is not only a detailed
explanation and instruction in the technique and concept, but a historical perspective on
its development.
Lawrence Kohan, PhD, FRACS, FAOrthA
Visiting Professor, University of Technology, Sydney
Consultant Orthopaedic Surgeon, Joint Orthopaedic Centre, Sydney
vii
Preface
What is LIA? Strictly speaking, local infi ltration analgesia (LIA) is a technique for man-
agement of the acute phase of postoperative pain, particularly after knee and hip surgery.
The technique was developed by Dr. Dennis Kerr and Dr. Lawrence Kohan in Sydney,
Australia, between 1998 and 2008, specifi cally to assist in improving postoperative out-
comes; it was fi rst published in Acta Orthopaedica April 2008 (1). Since then, develop-
ment has continued, minor modifi cations have been adopted, and its use has been extended
to other fi elds, particularly lumbar spine surgery.
The technique is based on systematic infi ltration of a mixture of long-acting local
anesthetic, a direct acting anti-infl ammatory drug, and sometimes other drugs (such as
steroids and clonidine) around all structures subject to surgical trauma. The intention is to
target all elements involved in generation of pain signals at the site of injury, including
nociceptors, nerve endings, nerves, and all active constituents of the biological soup
responsible for the infl ammatory response to injury. The technique also encompasses
measures, based on fi rst aid treatment of snakebite, to slow down the uptake of the drugs.
The duration of the block is extended by the use of a pain catheter to top up and re-inject
the joint by hand as the initial block recedes.
Many factors, including preparation, surgery, anesthesia, pain management, and
postoperative care, infl uence short-term outcomes after surgery. Local Infi ltration Analgesia
is merely one piece of this jigsaw puzzle of important contributing elements. Specifi cally,
it is the element designed to manage the Acute Postoperative Pain Phase lasting about
36 hours post operation, and should be regarded as a key enabling technique promoting
rapid return to the normal activities of daily living and facilitating discharge from hospital.
Although LIA is a technique for acute postoperative pain control, the focus of our
efforts has not been pain control per se, but rather to improve the overall rate and quality
of recovery from surgery and anesthesia, and then to use this advantage as a platform to
implement a cascading series of measures for improving overall outcomes. Rapid,
high-quality recovery makes it possible to avoid, reduce, or rapidly terminate all invasive
measures and to have people return to normal activity (including personal hygiene), with
dramatic improvement in the incidence of infection and venous thromboembolism (VTE).
Consequently, any assessment of this technique in comparison to other techniques for
pain control must include measures of postoperative quality of recovery and global
outcomes such as VTE and hospital-acquired infection rates since these were the concerns
that this technique was designed to address.
Because this key technique has also triggered important changes to other aspects of
pain management and perioperative care, the term LIA is also used in a much broader
sense to denote (or be a proxy marker for) our whole approach originally known as the
“Kohan/Kerr technique for pain management and perioperative care.”
I believe that clinicians are more akin to engineers than scientists. It is the clini-
cian’s task to stay abreast of the developments in science, and also transduce the mixture
viii
PRE F ACE
of science and experience into practical results. In common with engineers, this involves
a good deal of pragmatism and practical consideration of the constraints imposed by the
circumstances of each practice. In the real world, ideal results may not be achievable or
getting that last 5% may be too costly to implement, but often close approximations are
achievable and affordable. Engineers accept these practical limitations and, having
achieved a useful practical outcome, continue to polish the result with continuous quality
improvement techniques; in the end, they are able to achieve the closest possible approach
to the ideal outcome. This is exactly the process by which local infi ltration analgesia was
developed.
In private practice, there is no money, no staff, and very little time to devote to
research, but there is an abundance of clinical material. Randomized controlled double-
blind trials are also diffi cult to conduct from a private practice base. The time, money, and
documentation required for approval by ethics committees and government agencies are
a signifi cant impediment to research. In addition, normal medical indemnity insurance
does not cover clinical trials and obtaining private insurance to cover clinical trials is
costly and diffi cult. The practical alternative for private clinicians is careful observation,
documentation, and audit of outcomes with constant review to polish future practice.
The clinical trial approach is also not well adapted to the development of a new
technique such as LIA. Each aspect of this multifaceted approach would need to be the
subject of at least one separate trial, which would take an extraordinarily long time to
conduct and correlate into a unifi ed technique. We also consider it unethical to set up
placebo control groups or control groups using techniques that we know to be inferior.
The LIA technique has been used for several different types of operations. Some of
these operations have been of minor nature such as arthroscopy, unicompartmental knee
surgery, and anterior cruciate ligament surgery in which pain control and satisfactory
outcomes are much easier to achieve that is the case for total joint arthroplasty. Although
the information to be gained from minor surgery cases is useful for toxicity and side-
effect monitoring, the main focus of this book has been the use of the LIA technique for
total joint arthroplasty. The outcomes reported therefore refl ect this bias.
Some of the work in this book has appeared in part in other publications, notably,
from our original paper about the LIA technique (1) and from Chapter 30 in the book
“Modern Hip Resurfacing” (2). Although I have reworked the material to ensure its rele-
vance in this context, I have self-plagiarized some of the sentences and, occasionally,
whole paragraphs from these previous publications because I could not fi nd a better way
to say the same things.
I particularly wish to acknowledge the contribution of Prof. Lawrence Kohan,
orthopedic surgeon and our team leader. Prof. Kohan and I have been working together
for more than 15 years, and we have developed the LIA technique together. Many of his
ideas have been incorporated in the overall technique and he is responsible for developing
the systematic injection sequence. His support and encouragement have been invaluable
and, without access to his private patients, the technique would never have been devel-
oped. I also work closely with two other orthopedic surgeons who have contributed sig-
nifi cantly. Assoc. Prof. Peter Papantoniou has especially contributed to the development
of LIA for lumbar spine surgery and Dr. Sami Farah has assisted in reviewing the manu-
script. Two of our orthopedic fellows, Dr. Ikram Nizam and Dr Sandeep Biswall, have
contributed by investigating and documenting some of the outcomes associated with the
LIA technique. Finally, two Swedish medical students, Joakim Rostlund and Jesper
Benck, visiting during their elective term, provided valuable assistance in conducting
studies on ketorolac.
ix