No food for 6 hours before your operation.
It is okay to drink clear fluids up to 2 hours before surgery (water, clear fruit juice, black tea/coffee until arrival at the hospital).
Take all your usual medications except for diabetic tablets on the day of your surgery. Discuss use of blood thinners with your surgeon or anaesthetist especially if you have cardiac stents. Aspirin can be continued. Lyrica will usually be offered to all patients as a ‘pre-med’ (unless you have had prior problems with this medication).
The typical anaesthetic plan is listed below. This may be altered to suit your requirements.
Firstly, all patients will be asleep for the operation with a full general anaesthetic unless otherwise requested.
In addition to this we will use two types of local anaesthetic:
- A spinal injection
- Local anaesthetic in your hip joint, placed by the surgeon
This is a simple single injection in the lower back designed to keep your legs numb for several hours after your operation. It is done in the sitting position or lying on your side. The main benefits of a spinal injection is total pain relief for several hours after the operation and a marked reduction in the amount of morphine based pain medications used during this period. This often means less side effects relating to morphine medications such as nausea, drowsiness and itch.
The effect of the injection is to put both legs to sleep so that you will not be able to feel or move them at all for a few hours. It general requires insertion of a urinary catheter for the first night until full sensation returns. This is a safe technique and complications are uncommon. Serious complications are rare.
The spinal injection is recommended but optional. It does not contribute to low back pain and is considered quite safe however if you do not wish to have this injection please discuss this with your anaesthetist. If you have had spinal fusion surgery it may be more technically difficult and may not be offered.
Local Anaesthetic Injection
During your surgery while you are asleep the surgeon will inject a large volume of local anaesthetic directly into your hip joint. This is designed to help keep your hip relatively numb after the spinal injection wears off.
After Your Operation
If you have had a spinal injection, you will wake up with numb legs and be unable to move them for 2-3 hours. As the spinal wears off you may notice some pain in your hip. In most patients the discomfort is manageable and settles with additional pain tablets. Occasionally, in ~5%, or 1 in 20 patients, this pain may be more severe. The surgeon will have injected a large amount of local anaesthetic into your joint while you were asleep to help prevent this onset of pain. We will also give you a slow release pain tablet before the spinal injection wears off. If you still have pain despite these measures please call the nurse sooner rather than later for a pain reliever, usually a quick release pain tablet.
There are a range of medications used to help with pain management. It is important that you get to understand what these are and how they make you feel as all of these can have side effects. You will also need to know about these tablets as you will be taking some home following discharge.
Panadol (Paracetamol, Panadol Osteo)
This is a simple pain reliever, which should be taken on a regular basis to reduce your need for stronger medications. Take two tablets 3-4 times per day for at least two weeks. Panadeine Forte has codeine added for extra pain relief but may cause drowsiness or nausea or constipation. Do not take more than eight tablets of either medication in 24 hours.
These include Mobic, Celebrex, Nurofen and Naprosyn. Take with a glass of milk or after a meal. If you have kidney disease, stomach ulcers, heart failure or previous allergic reactions you may need to avoid these tablets. Otherwise continue to take these every day during the first week after surgery then once daily only if needed in the second week then stop. Some patients may continue to take anti-inflammatories longer term after discussion with your doctor.
This is an important pain reliever which can reduce pain during your hospital stay and also reduce the risk of longer term pain after your surgery. It may cause dizziness and drowsiness or occasionally hallucinations in some individuals. At higher doses it may also cause blurred vision which is relieved by reducing the dose. Initial dose is typically 75 mg
twice daily or simply once daily at night. If tolerated please continue to take Lyrica for two weeks after your surgery or at least until your pain is well controlled.
Stron Pain Killers
This is a newer painkiller for moderate to strong pain which can be very effective for pain. It comes as 50 mg slow release (SR) available twice per day or 50 mg immediate release (IR), which can be taken every 2-4 hours as needed. Initially you will receive regular PALEXIA SR and if you need additional pain relief then you will be offered the PALEXIA IR in addition. As you progress you may stop taking the PALEXIA SR if you no longer need it.
PALEXIA may have some side effects similar to morphine such as nausea, sedation & itch. Most patients will be prescribed PALEXIA but if required there are some alternatives listed below.
Alternative Pain Medications
- Targin – This is an alternative to Palexia. It is also available twice daily as needed. It may cause more nausea than Palexia.
- Endone (Oxycodone) – Comes as 5 or 10 mg available every two hours in hospital then 4-6 hourly when at home. It is a strong painkiller with a quick onset but only lasts ~2hours. This is good to take before physiotherapy or when pain is not well controlled.
- Temgesic – This tablet goes under the tongue and is similar to Endone but slightly slower in onset and longer acting.
- Norspan skin patch – This contains the same medication as Temgesic. Some patients will be offered a Norspan patch, which is applied to the skin and lasts one week. The patch comes in 5 or 10 microgram strengths. This may also cause the same side effects as above.
- Tramadol – Available as slow release (twice daily) or immediate release (x4 per day) this is for moderately strong pain and may suit some patients. However it is not well tolerated by all and sedation and nausea is not uncommon. Avoid if any history of seizures.
All strong pain medications have the potential for side effects, which include nausea, vomiting, dizziness, confusion, constipation and possibly hallucinations. If you are on strong pain relievers avoid alcohol, driving and operating machinery. Sedation may be improved by reducing the dose or taking the medication less often. If you feel excessively light-headed, spaced out or nauseated, try reducing your dose. If your symptoms persist try an alternative pain reliever or contact your doctor (see below). To prevent constipation, ensure you have adequate fluid intake and dietary fibre. You may also need to take regular laxative until you no longer need strong pain relievers. If you have a Norspan skin patch on and you have experienced persisting nausea or sedation the patch may have to be removed to alleviate the side effects and an alternative pain reliever used.
Alternative Pain Management Plan
Local Anaesthetic Infusion
Some patients who are having complex revision surgery or have had problems with pain management in the past may be offered additional pain management in the form of a continuous infusion of local anaesthetic. This will be delivered into a pain catheter placed at the start of surgery in the lower back. This has the effect of partially numbing the affected hip and thigh and reducing pain or need for other pain tablets. The catheter is placed close to the nerves supplying the hip joint. These nerves are called the LUMBAR PLEXUS. It will only affect one side and while the thigh muscles may be partially weak patients should still be able to mobilise. The catheter is inserted with local anaesthetic under sedation and is considered safe. Complications such as bleeding and infection are uncommon and serious risks including nerve injury are rare. The infusion would usually continue for 2-3 days after surgery via a small portable electronic pump.
It is important that you understand what medications to use when you leave the hospital:
The first two weeks
- Paracetamol (Panadol, Panadol Osteo) for at least 4 weeks.
- Anti-Inflammatories (Mobic, Celebrex, Nurofen etc.) for two weeks then stop. If you wish to continue these medications please discuss with your GP as longer-term use should be in consultation with your doctor.
- Lyrica should ideally be continued for up to two weeks after your surgery as it can be an effective pain reliever and may reduce the risk of persistent pain in the longer term. Should you experience unpleasant side effects you can reduce your dose or take only at night or stop altogether
- Palexia SR twice daily until your mobility is not significantly affected by pain. The duration of this medication is variable. Aim to reduce and stop this medication soon after discharge if you can mobilise. If you still require this medication beyond two weeks post-discharge please consult your doctor. PALEXIA IR may also be available post-discharge but usually only provides temporary relief and the SR tablet may be more useful.
After two weeks
- Stop taking regular Anti-Inflammatories. If you feel that you need to continue taking these please discuss with your doctor.
- Reduce or stop using the Palexia once your pain is under control.
- Stop taking Lyrica if your pain control is adequate and you no longer need PALEXIA. If pain at night is an issue it may be useful to continue taking Lyrica at night until this improves.
- Continue Paracetamol (Panadol or Panadol Osteo) on a regular basis until you no longer need any other pain medication
If you are still having difficulties with pain management after two weeks please consult your surgeon or GP for further advice and assessment
If you are having problems you can contact:
- Hollywood hospital: (08) 9346 6000 (ask to be put through to the ward)
- The Acute Pain Service: 0408 734105
- The Joint Studio: (08) 9386 3933 (Office hours)
- Your local GP
- Your anaesthetist: Dr. Mark Lennon