Summary Recommendations

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Summary Recommendations

The recommendations of the PROSPECT Working Group are graded A–D, based on the level of evidence from the studies, which is in accordance with the Oxford Centre for Evidence-Based Medicine (CEBM website accessed Dec 2003, Sackett 2000). In the context of PROSPECT, recommendations based on procedure-specific evidence are grade A, those based on transferable evidence are grade B, those based on evidence from case series are grade C, and those based on clinical practice are grade D (Click here to see the levels of evidence and grades of recommendation table). PROSPECT provides clinicians with supporting arguments for and against the use of various interventions in postoperative pain based on published evidence and expert opinion. Clinicians must make judgements based upon the clinical circumstances and local regulations. At all times, local prescribing information for the drugs referred to must be consulted. In summary, the PROSPECT recommendations for pre-, intra- and postoperative interventions for the management of postoperative pain in total hip arthroplasty are as follows:

Pre-operative

• Analgesic medication should be initiated in time to ensure an adequate analgesic effect in the immediate postoperative period (grade D)

Intra-operative

• The anaesthetic technique should be selected on the basis of minimum impact on the co-morbid state of the patient (grade D). The chosen anaesthetic technique can be continued, or may have a continued effect, for analgesia postoperatively (see Postoperative)
• Analgesia, other than that required for adequate anaesthesia, is recommended only if the analgesic agent requires time to have maximum effect in the early postoperative recovery period (grade D)
• For long-term analgesic benefits, cemented prostheses rather than non-cemented prostheses are recommended (grade B)
• Surgical drains are not recommended because they are associated with an increase in discomfort (grade A), pain scores and risk of infection (grade B)

Postoperative

Systemic analgesia

The following are recommended:

• COX-2-selective inhibitors (grade A) or conventional NSAIDs (grade B) (depending on patient risk factors) – in combination with strong or weak opioids, as required for pain intensity
• Strong opioids (grade B) – in combination with non-opioid analgesia for high-intensity pain, preferably administered intravenously by patient-controlled analgesia (grade B) or fixed-interval injection (grade D)
• Weak opioids for moderate- or low-intensity pain (grade A) if conventional NSAIDs or COX-2-selective inhibitors are not sufficient or are contraindicated
• Paracetamol (grade A) – for all pain intensities in combination with conventional NSAIDs or COX-2-selective inhibitors (with or without weak opioids)

Regional analgesia

The following are recommended:

• Peripheral neural block continued after surgery (grade A) in combination with systemic analgesia as required for pain intensity (as above)
• Spinal LA and opioid as a ‘single shot’ given pre-operatively (grade A) (continuous infusion or repeat bolus spinal is not recommended, grade D), then systemic analgesia as required for pain intensity (as above)
• Epidural analgesia continued after surgery, only in patients at high cardiopulmonary risk, and then systemic analgesia as required for pain intensity (as above)

See Overall PROSPECT Recommendations for the overall strategy for managing pain after total hip arthroplasty