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TOTAL HIP REPLACEMENT

Antibiotic prophylaxis:

1g vancomycin and 120mg gentamicin at induction only (iv).

Thromboprophylaxis (low risk cases):

Calfpump or footpump from recovery throughout hospital stay when patient recumbent during the day; at night if tolerated.

Fragmin 2500u s/c starting 8 hours after surgery for the period of hospital admission only.

Aspirin (150mg) once daily for 6 weeks after discharge.

Thromboprophylaxis (high risk cases):

Footpump as above plus Warfarin for a period of 6 weeks, commencing on day of surgery in the evening (target INR 2 – 2.5). Fragmin 5000u until INR is in the desired range. INR should be >2 for two consecutive days before stopping Fragmin.

Urinary catheterisation

All patients having an epidural (or spinal opiate) to be routinely catheterized in anaesthetic room prior to surgery. Catheter removed morning of first post-op day.

Hydration

In routine primary cases at least 2 litres Hartmans in theatre.

Post-op: 1 litre Hartmans over 6 hours followed by 1 litre Dextrose saline over 10 hours. Discontinue if patient drinking.

Mobilisation

Stand and mobilise with walking aid on the day of surgery wherever possible. Full WB unless specified on operation note and dispense with walking aids when safe to do so.

Aim for discharge third post-operative day for routine primary.

Alimentary tract

Avoidance of opioid analgesia wherever possible. Docusate Sodium:  200mg Oral at bedtime starting day of operation and then b.d. until discharge.

Drain/dressing

Drains not routinely used. Removed day 1 if drainage low. Opsite dressing left in place until discharge.

PAIN RELIEF

The importance of a carefully designed plan for anaesthesia and analgesia cannot be over-emphasized. The unit policy in the majority of cases is highlighted:

Routine analgesic protocol (unless NSAIDs contra-indicated)

Pre-operative

Paracetamol 1g plus Diclofenac 50mg plus Omeprazole 20mg to be given 30 minutes before surgery

Intra-operative

All patients to have spinal anaesthetic with Diamorphine when possible.

Epidural anaesthesia for revision or complex primary procedures. Removed day 2, exact timing according to local policy on epidural removal and anti-coagulants

A field block may be performed by the surgeon during wound closure:

20 mls Marcaine 0.25%

20 mls Marcaine 0.25% with adrenaline

40mg Paracoxib (20mg in patients less than 50Kg weight), only after discussion between surgeon and anaesthetist

Morphine sulphate 10mg (but not for patients who have had spinal morphine)

Made up to 100 ml with N-saline. Delivered through 18G spinal needle.

(No re-infusion drain to be used with field block).

Post-operative

At 3hrs post-op patients to be given 1g Paracetamol.

Thereafter regular prescribed analgesia:

Paracetamol 1g QDS + Voltarol 50mg TDS (max 150mg in 24 hrs, omit during first 24 hours if field block given) + Omeprazole 20mg.

Plus Codeine (30-60mg QDS) or Tramadol 50-100mg Sublingual QDS – PRN

Plus Oxycodone 5mg p.o. or i.m.  One or two doses only in exceptional circumstances.

Post-discharge

Regular paracetamol +/- NSAID’s.

Plus Tramadol or codeine only if necessary.

Benefits of Fast Track Rehabilitation.

Venous thromboembolism

Early mobilization has to been shown to be protective against this potentially life-threatening complication.

Gastro-intestinal complications

Ileus and constipation can be reduced or prevented.

Gastro-intestinal reflux reduced with early restoration of up-right posture.

Muscle strength

Early mobilization reduces degree of weakness induced.

Other joint/spinal disease

Early mobilization prevents painful stiffening from enforced supine bed-rest.

Hospital-acquired infection

Early discharge reduces the exposure to such infectious agents (e.g MRSA).