PAIN
RELIEF
AND ANAESTHESIA

Pain relief

Having any major operation results in some pain which if not controlled, can hamper your recovery. The care pathway here at the centre combines pain management before, during and after surgery, with a shift from general to local anaesthesia. Evidence shows that this the best option for most patients, resulting in significant reduction and better control of pain. However, everyone experiences pain differently (sometimes known as a ‘pain threshold’) so our team will ensure that your pain relief is adjusted to your specific needs.

The benefits of having good pain relief include:

  • Being able to get up and move around more quickly after surgery
  • Reduced post-operative complications, including
  • Having more restful sleep
  • Being able to leave hospital as soon as possible

Your surgery will, most likely, have been performed under a regional anaesthetic. The effects of the anaesthetic will last up to 3 hours after your surgery has been completed. Once the effects have worn off, the mainstay of your pain relief will be in the form of oral medication.

Your nurse will regularly ask you how you’re feeling and how much pain you are experiencing. They may ask you to ‘score’ your experience of pain on a scale of 0-10, where zero is no pain and 10 the most severe.

If you experience pain during physiotherapy/exercise sessions, tell your physiotherapist so that you can have appropriate pain relief. It’s important that pain does not hold you back from doing exercises designed to help your recovery/ mobility.

Pain relief medication (or analgesia)

The pain relief programme at the Fortius Joint Replacement Centre is based on the World Health Organisation’s pain ladder and is designed to minimise pain and side effects whilst best maintaining your ability to recover and rehabilitate. The general principle is to start with first step drugs, and then to climb the ladder if pain is still present. The medications range from common, over-the-counter drugs at the lowest rung, to strong opioids. Your personalised pain regimen will consist of all or some of the following medication.

  • Paracetamol (either oral or intravenous)
    • Paracetamol is be used after surgery to reduce the amount of stronger, opioid medications you need to control pain. Researchers believe it works by increasing the body’s tolerance of pain but they’re not yet completely sure of this.
  • Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
    • NSAIDs reduce swelling, soreness (and fevers) and are used for mild to moderate pain relief. However, to manage pain after surgery, NSAIDs are often used in combination with opioids. Examples of NSAIDs include aspirin, ibuprofen, and diclofenac.
  • Weak opioids such as Tramadol
    • Tramadol works in the brain and spinal cord to change the way the body senses pain. It works in a similar way to some antidepressant medications, by interfering with the regulation of the neuro-chemicals serotonin and norepinephrine, which makes it difficult for pain messages to be passed from one nerve cell to the next. Although tramadol can be effective in treating moderate pain, it is most effective when used in combination with paracetamol or NSAIDS.
  • Strong opioids in the form of oxycodone
    • Opioids are substances that act on opioid receptors to produce morphine-like effects. Opioids are most often used medically to relieve pain and are available either in a slow release oral form or an immediate release oral form. During your hospital stay, you will receive regular slow release oxycodone. Immediate release oxycodone will also be available to help you deal with any additional pain.
  • Neuromodulators in the form of pregabalin
    • Pregabalin significantly decreases pain while increasing and assisting mobility after surgery. It is taken over a 2 week period starting on the day of surgery.

Side-effects of pain relief

Anti inflammatory drugs can cause gastric irritation so you will be asked to take regular medication to protect your stomach lining. Opioid pain relief medication can cause side-effects including nausea, vomiting and constipation. You will be taking regular medication to maintain bowel function and additional medication is available to counter the other effects.

Consent

All surgery carries some risks. In most cases, complications can be prevented or easily treated by taking the right precautions and prompt action when necessary. However, it’s important to discuss any likely complications with your surgeon and anaesthetist before your procedure, especially if you have a pre-existing existing medical condition such as high blood pressure or diabetes. You’ll be asked to sign a form consenting to your surgery before the procedure.

  • Your Anaesthetic

Modern drugs, equipment and training have made anaesthesia – a much safer procedure. Researchers are continuing to investigate new methods of pain management including different drug combinations and delivery methods. While serious reactions to anaesthesia are uncommon, you may still experience some side effects and all anaesthetic procedures carry a degree of risk.

At the Fortius Joint Replacement Centre we aim to provide our patients with the safest treatment pathway that not only speeds up your recovery, but also keeps pain and the risks associated with anaesthesia to a minimum.

Before your surgery you’ll have an opportunity to meet the anaesthetist who will be managing your pain relief and wellbeing during your operation. You’ll have an opportunity to discuss the various options, including the advantages and disadvantages of each and any risks involved.

Most patients choose to have regional anaesthesia and this is the method most often advised. However, it’s important to know that this may not be the right option for you.

For knee replacement surgery most anaesthetists will also perform an adductor canal block and details of this technique are given below:

Regional Anaesthesia

This means you will be numb from the waist down (the ‘region’ anaesthetised) and feel no pain during the operation. You can also be asleep if you wish. It is different from a ‘general’ anaesthetic where you are unconscious with a breathing tube in your throat. The main type of regional anaesthesia offered is a spinal anaesthetic.

Spinal Anaesthesia

Local anaesthetic is injected near to the nerves in your lower back.

  • You are numb from the waist downwards.
  • You’ll feel no pain, but you remain conscious.
  • You will be offered sedation, which makes you feel sleepy and relaxed or even completely asleep.
  • It will take 3-4 hours before normal movement in your legs returns.

Advantages – compared to a General Anaesthetic

  • There will be less sickness and drowsiness after the operation and you may be able to eat and drink sooner.
  • It helps to avoid blood clots in the legs and lungs.
  • Less bleeding during surgery and you will be less likely to need a blood transfusion.
  • You remain in full control of your breathing and you will breathe better in the first few hours after the operation, reducing the risk of chest infection.
  • Most patients do not need such strong pain relieving medicine in the first few hours after the operation.

Because of the advantages a spinal anaesthetic gives you, we recommend this type of anaesthesia for your operation.

Epidural

Occasionally, patients are offered an epidural in combination with a spinal or a general anaesthetic.

A small plastic tube (an epidural catheter) is passed through a needle into a place near to the nerves in your back. You receive local anaesthetics and pain relief drugs through this tube, relieving pain and reducing all feeling in your lower body.

Although operations can be done with an epidural alone, it is more commonly used for those operations that:

  • are expected to be very long, for example, more than 3 hours
  • are likely to be particularly painful afterwards.

Advantages

  • An epidural can be topped up with more local anaesthetic, and therefore its effects can be made to last longer than a spinal anaesthetic.
  • It can be used to make you comfortable for several days after the operation.
  • It also has all the advantages of the spinal anaesthetic shown above.

What happens during a Regional Anaesthetic?

  • Your Anaesthetist will ask you to keep quite still while the injections are given.
  • You may notice a warm tingling feeling as the anaesthetic begins to take effect.
  • Your operation will only go ahead when you and your Anaesthetist are sure that the area is numb.
  • If you are not having sedation you will remain alert and aware of your surroundings.
  • A screen shields the operating site, so you will not see the operation unless you want to.
  • Your Anaesthetist is always near to you and you can speak to him or her whenever you want to.
  • Sedation will allow you to sleep throughout the procedure.
  • You may listen to music of your choice once in the operating theatre.
  • You’ll be given additional oxygen to breathe.
  • A warming blanket will be placed over the top half of your body

General anaesthesia

General anaesthesia is often used for major surgery, including joint replacement. However, unlike regional anaesthesia, it affects your whole body and means you are temporarily unconscious, during which time you will not be able to feel anything.

Disadvantages and side-effects

  • A general anaesthetic is given by injection or inhalation, but the anaesthetist will also need to place a breathing tube down your throat to give you oxygen to help with your breathing and/or make sure that the anaesthetic gases reach your lungs. This tube may give you a sore throat for a few days.
  • The general anaesthetic affects your heart and breathing and there is a small risk of serious medical complications including a heart attack or stroke. Headaches, nausea, drowsiness, light headiness, blurred vision, and shivering are more common side-effects.
  • You may also feel a little confused and complain of memory loss. This is more common in older people but the effect is usually only temporary.
  • The side effects of the general anaesthetic may mean you spend longer in bed and so begin to exercise your knee later than is ideal which may slow your recovery/mobilisation.

Adductor Canal Block

Patients having knee replacement surgery may also have an Adductor Canal Block. The adductor canal is an anatomical structure half way up the thigh that contains the saphenous nerve as well as the artery and vein. The saphenous nerve supplies sensation to a significant proportion of the knee and so depositing local anaesthetic around this nerve will improve your pain relief after the operation. Also, significantly, this technique does not impact upon the muscles ability to function which will enable you to be able to do your physiotherapy on the day of your procedure.

The local anaesthetic is deposited in the form of an ultrasound guided injection. This is done once your regional anaesthetic is working or, if you are having a general anaesthetic, once you are asleep.

The risks and potential side effects are minimal and it has been shown to be a safe and effective additional pain relieving technique.

Fortius Joint Replacement Centre
at Bupa Cromwell Hospital

164 -178 Cromwell Road
Kensington
London
SW5 0TU


E: info@fortiusclinic.com

Appointments: +44 (0)203 693 2119

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