Study Comparing a Nerve Block With Spinal Opiate to Provide Pain Relief for Hip Replacement Surgery
Condition: Analgesia
MeSH terms: Agnosia
Study type: Interventional

Summary: 
      Pain control after hip replacement surgery is important to ensure patient comfort, allow
      mobilisation, and aid recovery. The investigators propose a simple and pragmatic study
      comparing two different anaesthetic techniques in the provision of pain relief after hip
      surgery. Patients will be randomised to receive either spinal anaesthesia containing morphine
      or spinal anaesthesia without morphine and an ultrasound guided fascia iliaca nerve block.
      Although morphine is an effective pain killer, its side effects include itch, urinary
      retention, nausea and potentially fatal breathing problems. If the nerve block can be shown
      to provide comparable pain relief to spinal morphine, then morphine could be removed from the
      spinal injection. This could reduce side effects and improve patient safety. The
      investigators wish to investigate whether ultrasound guided fascia iliaca plane block
      provides analgesia which is comparable to that of intrathecal opioid for primary hip
      arthroplasty in the first 24 hours after hip replacement surgery
    

Detailed description: 
      There were 6312 primary hip replacements performed in Scotland during the one year period
      2007 - 2008. Patients undergoing hip arthroplasty commonly have significant comorbidity and
      associated polypharmacy providing many potential challenges for the anaesthetic doctor. The
      optimal way to anaesthetise these patients remains to be fully established although many
      potential methods exist. The main choice is between general anaesthesia (GA) and regional
      anaesthesia (RA) or a combination of the two. In a recent systematic review, RA was found to
      reduce post-operative pain, morphine consumption and nausea and vomiting compared with
      systemic analgesia.

      Spinal anaesthesia is a popular form of RA used in many patients undergoing hip arthroplasty.
      Opioid drugs are frequently added to the spinal injection in order to prolong post-operative
      pain relief. However, this is associated with side effects including respiratory depression,
      urinary retention, nausea and vomiting, and pruritus. Such adverse effects may be
      uncomfortable for the patient and can delay mobilisation, recovery and eventual discharge.

      In patients undergoing hip arthroplasty, peripheral nerve blockade has been shown to improve
      pain scores and reduce morphine consumption. A peripheral nerve block called the fascia
      iliaca plane block has shown significant promise as a method of providing sensory blockade of
      the main nerves which supply pain to the hip. The use of ultrasound for the performance of
      fascia iliaca plane block has been shown to increase reliability compared with the landmark
      technique though the clinical benefits of this have not yet been fully investigated.

      Compared to nerve stimulation or landmark techniques of nerve localisation, ultrasound has
      been shown to increase success rates, reduce block onset time, increase block duration,
      reduce volumes of local anaesthetic required and increase patient satisfaction.

      The investigators hypothesise that by increasing the success rate of the fascia iliaca block
      with ultrasound, it will be possible to achieve superior analgesia post-operatively. Our aim
      is to assess whether the ultrasound guided fascia iliaca plane block can be used as an
      alternative to intrathecal morphine in the provision of post-operative analgesia for primary
      hip arthroplasty. If this is the case, intrathecal opioid could be removed from the spinal
      anaesthetic. This could in theory have significant safety benefits whilst also reducing side
      effects. Ultrasound guided fascia iliaca block has not yet been evaluated clinically as a
      method of providing post-operative analgesia following primary hip arthroplasty. The
      investigators believe that further investigation of this technique will provide a valuable
      contribution to existing knowledge and will change current practice.
    

Intervention name(s): ultrasound guided fascia iliaca block; spinal morphine
Intervention type(s): Procedure; Procedure
Intervention description(s): Spinal anaesthesia with hyperbaric bupivacaine at a dose between 10 and 15mg as deemed appropriate by the anaesthetic doctor performing the spinal injection, no spinal morphine and ultrasound guided fascia iliaca plane block using 2mg/kg levobupivacaine diluted to a total of 40ml with sterile saline.; Spinal anaesthesia with hyperbaric bupivacaine 10 - 15mg as deemed appropriate by the anaesthetists performing the spinal injection, and with the addition of intrathecal morphine 100 micrograms. Sham fascia iliaca plane injection with saline.
Intervention MeSH terms: Morphine
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Quadruple (Participant, Care Provider, Investigator, Outcomes Assessor)
Primary purpose: Treatment
Keywords: anaesthetic techniques, regional; analgesia, post-operative; fascia iliaca compartment block; ultrasound guided; surgery, orthopaedic